M. PARKER ernia

uh good morning can you hear me in rome hello yes hello i can hear you okay welcome in rome

sorry i couldn't hear that well say again welcome in rome ah thank you very much thank you you can

hear me yeah we've got a very interesting case this morning to show you which is a lady with

obstructive defecation syndrome she's in her 40s and she's had symptoms for about six years

and the symptoms are those whereby she has to digitate in the posterior wall of the vagina

in order to be able to defecate and to cut a long story short on um on examination with

proctography and uh with uh looking with a proctoscope you can actually see intra-anal

interception with the rectum coming right down into the anal canal and on the proctography which

which I can't show you, unfortunately, but I can tell you she has a rectocele and interception

and an enterocele, so she's got full house. She's got everything. I'm just putting the ports in now,

so if we can have a sheath, please, and then we'll have a look and see inside. We had a little

bit of trouble just getting a decent view. These are step ports, which is what I use routinely.

Five millimeter, please, and once we've got this in, we should be able to have a look, and then

you'll see the rest of the ports going in that sounds good camera please thank you right so

we'll have a look inside here we go that's the view it just needs to be a little bit clearer

so we'll focus it there we go and i'll just turn the view round we use a 30 degree scope

i'm sure all of you are familiar with this just have a look and see how much damage we've done

with the varus needle nothing that's looking good so can we have steep trend can you take this down

so that i can't see you steep trend ellenburg please if you would that's lovely really keep

going now you can see the momentum which is moving out of the pelvis keep going to that please and

can you take these legs down please make them both go down so she's had a vaginal hysterectomy in the

past so we're anticipating that there might be some adhesions in the pelvis and indeed there

There are a few here.

It's typical of these patients that they do have had a hysterectomy in the past.

That's what you'd nearly always expect.

But we'll remove those adhesions and then get rid of the omentum.

So to do that, we need two more ports in.

And I put them pretty much parallel with the first port.

If you can zoom in the wall camera here now, we might be able to show them this,

the positions of the ports.

There's the needle.

Betty look at the screen tell me when they've got the wall camera view okay these mustn't be

too high but mustn't be too low either otherwise you can't get over the rim of the pelvis and you

put these pretty much full in otherwise you can't reach right down to the pelvic floor

then we put one on this side now this side we put a 10 or 12 millimeter port

because we've got to be able to got to be able to get the mesh in on this side so it's a slightly

bigger hole but this is the biggest hole she'll have will be 10 millimeters that's it just there

i always put some marcane and adrenaline just on the peritoneum here like this and then hopefully

they don't get too much pain afterwards i have no objective evidence whether that works or not

but it seems to make sense to me. That Markane will spread to where we've put the port and I'm

aiming it towards the pelvis. You might be able to see that on the wall cam. And now we attach

the gas to the 12mm port so that we've got good view throughout. Okay, so now we've got the ports

in place, just the three, and now we're looking down into the pelvis. That's why I want the camera

camera help please somebody? Whichever side you want. Grasper please, and ultracision.

Okay, can we turn some of the searchlights out? Thank you. We're just testing the ultracision

now. That's fine. So one and five, yes. Good. So now we're ready to start this operation.

You can see the scar here from the previous hysterectomy. So we'll just take that down.

down, that's fine, keep very still there. Put an extractor on the left hand side please.

Say again? What pressure? What is it? Yeah, down to 15 please, thank you Susan. Put the

pressure down to 15 please. There we go, now come back with the camera, and now we should

see all the omentum. Another grasper please. All we want to do now is get a view, so we

We take the small bowel out of the pelvis.

Just look up here, Sarah, please, back here.

Look down.

There's the sacral promontory here.

Okay, so we've got the sacral promontory there,

and that's going to be the top part of where we put the mesh in a few minutes.

Come further back so that I can see the small bowel.

It's still a bit adherent here, but I don't need to mobilize that.

That will be okay.

I have sufficient view now.

So look down into the pelvis again.

Stop, and don't go further in than that.

Here's the sigmoid, which we take out of the pelvis.

And now you can see the extent down here where we're going to go.

Stay back, Sarah. Come back.

I'm going to start up here on the promontory.

You can see here the right ureter.

There it is.

We put uroglose in so that we can identify the ureter easily.

It's coming up here and then going down there.

And on the left side, I think it's about there.

There it is, underneath the left ovary.

so we can see the ureters clearly now that one doesn't matter but this one does we're going to

go from here down along parallel to the rectum and right down to the bottom now follow me and

sarah if you go right down here you can see this huge sort of gutter that she's got this is a deep

pouch of douglas and what i'm going to do is excise all of this area here because that's where

she's getting the enterocele going down there and eventually she'll have a new pelvic floor

which will look hopefully a lot better by the end of the operation. Right, let's have

ultracision please. Come back to the sacral promontory, Sarah. Okay, so this is where

we start the operation. Just move that slightly further back if I can. I'm just going to hang

on to the rectum. Here's the promontory up here. There's the ureter out there, so I just

need to start somewhere about here and i literally just make a little hole to start with

there we go come in a bit sir that's fine stay just there and we literally just go down parallel

to the rectum are you hearing me okay in rome is anybody there yeah sure i hope you can hear me

okay yeah good okay if you want to ask any questions please do yeah do you do you put

always some progress into the ureterra for pelvic operations I tend to because

especially if they've had previous surgery this girl had had a previous

vaginal hysterectomy now as it happens she had very few adhesions but sometimes

you find that they have really bad adhesions or for some reason it's

difficult to see and it's just nice to have the security of the of the

uroglows, and sometimes I put them in expecting very few problems, and I've been very, very

glad that I've got a uroglow in. It's been really very helpful to have them there. So

I'm going down just by the side of the rectum. Follow me in a bit, Sarah, down there. And

I'm heading for the junction of the rectum and the vagina, which is down here somewhere.

Come in a bit closer. This, of course, is an anterior rectopexy. It's a ventral rectopexy.

So we tend not to go posteriorly too much, a little bit, but not too much.

Come further down.

Now, in a man, of course, if you were doing this, you'd go across here, anteriorly, up on the seminal vesicles.

But in the women, we tend to go out and down a bit.

In fact, I'm going to go around here, because I think all of this needs to be excised.

Do you see this pouch of Douglas?

it's that's that's part of the problem and I want to excise most of that it

seemed to be very very deep Douglas it is deep isn't it and that's part of her

problem as I say she's got a rectal seal she's got intra rectal interception and

she has an entra seal as well so she's got everything and although you can't

see those here at the moment they showed up very clearly on proctography and I'm

sure that's the cause of her six years of misery that she's had so we have now

to excise all this this can be quite difficult this because the tissue planes

are a little bit disturbed by the previous surgery and the fact that

they've been moving around in the wrong place for six years but you just have to

keep your eye on the anatomy can you move that thank you that's fine so we're

just keeping a vague eye on the anatomy, and we come anteriorly across here, and I'm probably

going to be aiming for somewhere about down here, I suspect, on the front wall, across the front

wall of the rectum, so that we've got complete mobilization of the lower rectum, and I'm able to

see where to put the mesh. Is the extractor on? Okay, that might be enough there. Just come back

a little bit sir that's fine I can use the back of this instrument as well as the front so I just

tidy this up a bit make sure there's no bleeding and come right up to the top because we do have

to get it off the sacral promontory up here because that's where we're going to staple the

mesh onto so I just want to do a little bit more up the top now now as usual with laparoscopic

surgery the secret is finding the tissue plane just come in a little bit that's fine so I've

I've just got to find the right plane here.

And there it is.

Just come in close here, sir.

You can see here what I call the cheveux d'ange.

I'm not a very good French speaker, but you can see the angel's hair there.

And that's telling me that that's probably the right plane.

So if I find the right plane, usually the dissection is done almost by itself.

You can see in here I'm coming in into that plane.

Just come back a little bit.

Again, I just need a little bit more here.

Come right back, sir.

just want to feel where that promontory is it's there you can see the promontory so this is where

we're going to be stapling the mesh to in a in a few minutes when we've done this operation

so i just want to clear this area here a little bit up that's that's the right plane there and

now you can see it very nicely with the cheveux d'ange i've got exactly the right plane so i don't

do too much posteriorly but you have to do some otherwise you can't actually put the mesh in

against the sacrum that's where it's got to come up to about here come back it's got to it's got

to be attached there so the mesh is going to lie from about here going down here on the sacrum

and then it'll come across the front of the rectum here and the back of the vagina so i just need to

do a little bit more here just to give us the room to do this and again you can see the angel's hair

so i take that i don't have any problem with dissecting this that's fine that's fine i'm just

going to go down laterally now no more posterior but i'm pulling on the rectum all the time to

bring it out you see the more i pull the more room i'm getting actually all the time so i just go

down laterally now and every time i do one of these cuts you can see that the rectum is coming

out of the pelvis here's the chevaux d'ange you see it's beautiful avascular plane don't have to

to do anything more down there, but I'll just carry on down here a bit. Some people don't do

anything latchly. I think that's probably wrong. I think you do need to do some here because you

want to bring the rectum out of the pelvis like that. Just make sure we haven't got any bleeding.

That looks okay. Quiet, please. Okay, that's looking good. So we're coming down to the

difficult bit. And in a minute, what I'm going to do is to ask one of my assistants

distance. Gabor here, who's from Hungary, who's going to help us at the bottom end.

And he'll be putting a swab on a stick in the vagina, and we'll be pushing the vagina

superiorly and anteriorly. There's the swab on the stick coming into the vagina. And first

of all, you push it posteriorly, Gabor, please. That's it. And now just lever it anteriorly.

Okay, that's fine. Now, in a moment, we'll swing the camera around, and you'll see how that helps

us to do this dissection down into the rectovaginal space, which is here. You can already see part of

it beginning to show with the chevaux d'ange, but I have to do a little bit more dissection. Now,

you can see this pouch of Douglas. It's even wider than I originally thought. It's including

this down here as well so we may have to take some more of it later but we'll see in a moment

so what i want you to do is to spin the camera light lead round that's it that's enough and then

show me down here that's it over the top of the rectum that's fine okay now i've still got to

take this off so i'm going to spin that round now just stay where you are so don't show me the

rectum at the top here. Okay, I'm coming. You can see the problem, of course, is whenever you let

go of the rectum, it shoots back down again, which is what her problem has been for a long time,

down into the pelvis. So we've just got to come a bit closer in, please. That's right. Now,

just want to see some anatomy here. That's where we've gone on the outside. Okay, this is the bit

bit that I'm going to be excising fairly soon. You can see it's just redundant part of the

pouch of Douglas, so I might as well take some of that now. But before I do that, I

just want to see exactly where the rectum is. Just come back a little bit, swing the

light lead round for a moment. We change the angle on the camera to show us exactly where

we are. Okay, so here's the rectum going down there, and I've got to keep a close eye on

that because it's very easy to get this this is the deep bit that's got to go you can see that big

sort of gaping cavity now angle the camera just to show not the light lead the camera just to show

me that in fact if you bring it hold the camera tight a little bit from that side that's right

just hold it there for a second i just want to see where the rectum is okay i think that's safe

there. Now I will admit to you that this bit can be difficult because you've got to actually see

where the anterior rectal wall is. I haven't seen it clearly yet. With all the scarring from the

previous surgery, it's not always obvious. So we'll just take this slowly, slowly, little by

little. There's the posterior bit. That might have to go as well, I think. That's, yeah, this needs

to go. So I just take this very slowly, looking out for the rectal wall

posteriorly and the vaginal wall anteriorly, but the vaginal wall I can

tell you is up here somewhere. There's a lot of fat here, it's been sliding for

many years this, it's not easy. I'm getting a slightly lateral view, so

let's come back again and just see where the rectum is. The secret is to keep the

attention on the rectum if we can, like that. That's fine. I'm just going to take that across

here a little bit, just to go out laterally a little bit more. It's better. Now I'm beginning

to see the rectal tube here. Front wall of the rectum is going to be under here somewhere.

So again, just over so gently because I don't want to damage the rectum. Okay. Sometimes I will put

an extra port in to hold the rectum. In fact, I think I'm going to do that now because I'm going

to need that fourth port in anyway a little later on to put the protac in so i might as well use it

now so we'll just put a little five millimeter port in here and i'll use the scar from her

previous surgery so in the midline and you'll see in the midlines right in the midline you'll see

this coming in i'll try and get it in the midline anyway it's difficult so there we go that's pretty

pretty much midline. I just put a needle in there and then insufflate a bit of

marcaine and adrenaline just to try and keep her comfortable after the operation.

This is a five millimeter port and this comes in because you need this to get the angle to

put the protac in. But I might as well use it at this stage so that I can actually hold the rectum

up and I'll ask one of the assistants to hold that. So if I can just have a grasper please.

please. Thank you. Now, Batty, I'm going to ask you to hold this if you don't mind. Just

look down onto the rectum, please, Sarah. Switch the light lead round. That's good.

And what I'll do is pull the rectum there. Batty can hold it about here. And just keep

that slightly on a stretch, Batty, please. You got it? Okay, that's great. I can carry

on now. Sarah, you and I come back in here. Just step back a little bit, Batty, would

would you? Thank you. Okay, now that keeps the rectum on the stretch, which is quite helpful

because you can sort of see. Come in a little bit. That's good. Just looking in here, Sarah,

I want to see what's going on there. That's anterior rectal wall. Switch the light lead

around so I can see it. Yep, that's much better. So we're beginning to see the anterior rectal wall

here, okay, and we've got to bear that in mind because that's where we're going to be putting

the mesh we want to get rid of this excessive redundant pouch of Douglas so

now that I can see that it's a little bit easier to do this eventually once

I've done it you'll think oh well it's obvious where it was but it can be a

little tricky at times at this moment we've just got to be very careful of the

rectal wall and I literally just sort of circumcised this I just keep taking it

until it comes off the rectal wall okay now that's redundant pouch of douglas or part of it so come

back with the camera and i'm not going to take that out just yet i'll just put it somewhere

over here perhaps looking towards the right alley at fossa and i'll just put it down there

now somebody please remember where that is because we must take that out at the end i'll just park it

there okay now come down here again sarah there's a bit more still to do of this i think maybe not

that's quite a lot better. Right, well we'll have a look later to see if we need to take any more of

that. Now what we have to do, this bit I think we'll have to go later, but I'll hang on to it

for the moment. Now what I want to do is to find my way into the rectovaginal space. So

light lead round to the back. Okay, so as I'm looking, keep your eyes on the screen when you

do that. Come in here and keep it anterior up there. That's right. It's very important to be

well orientated now the vagina just push that stick in a bit and go up anteriorly that's pushing

the vagina up and the rectum is here so this is the space between the two so this is the space

we have to dissect come in a little bit that's fine so i'm holding on to the rectal wall here

very gingerly here because of previous surgery it's just not quite clear where the

the line is. So I take this rather gingerly, rather gently. Sometimes the rectum can tent

up like that. A little bit to the side. Now I don't want to go too far posteriorly there,

there's no need. But this is the space that I'm looking into. And one of the things to

do is to let the air, the CO2, do part of the dissection for you. So we just try and

get a bit of air in here to see where we're going. Something behind me making a lot of

of noise sorry about that that's it I've still got to come in here this is just come down in here a

bit Sarah we've got to still find our way into that space a little bit so very very I'm going

millimeter by millimeter to find this space in somebody who's had no previous surgery it's a lot

easier of course but most of these women have had a hysterectomy of course that's part of the

the problem in obstructive defecation syndrome. About 90% of them have had a hysterectomy.

So have a hysterectomy and you know what's going to happen. Yep, avoid the hysterectomy

if you can. Okay, let's just look over here a little bit. I just can't quite see the plane

here. I think that's vaginal wall there. Can you just push that swab on a stick in

again. And I want you to push it posteriorly now. Just come back. Just take it back a little,

Gabor. Now push posteriorly. Remember, she's in steep Trendelenburg. That's better. Now lift it

anteriorly without taking the pressure off. That's good. That's great. Okay, that's fine. Come in

here again, please. We're trying to just see this space, and it's been a little bit clogged up by

the scarring from the vaginal hysterectomy. It doesn't help. A lot of fibrous tissue here,

a lot of scarring. Not obvious where the plane is at all. What I might ask you to do is to put a

rectal probe in as well. Just going to take a little bit of the lateral side here because I

need to get down as far as the pelvic floor so I've got to be absolutely certain how far down

we are here. There's no point doing this unless you go right down to the pelvic floor. We're

putting a rectal probe in now which should come up somewhere here. Have you got it in? Have we

we got a rectal probe? It's behind you, Gabor. I think that's the line here, just across here,

but I just want to be absolutely certain. Thank you. Just put the biggest one in. A lot of grease

on it, yes? Okay, so I'm pretty sure that the line is here. I think this is vagina and this is rectum

and that's the line that I need to go across, but I just want to be absolutely certain.

okay that's fine now push it in and posterior that's great and keep the

vagina anterior so this is this is the plane pretty much here I'm pretty sure

of that so let's work on that principle close in please sir that's lovely just

keep it there that's fine as I say it's it's easier in those who haven't had

previous surgery but it's not impossible I just have to be very careful so we're

winning here slowly but surely. Okay, I'm just going to pull the camera back and push the port

in a bit so that you can come a little bit closer. That's the view I want. That's lovely. Come back a

bit first. That's my instrument. There it is. Okay, come in. Okay, so that's the back wall of the

vagina there. So I just want to take this millimeter by millimeter. You go fairly slowly here because

you don't want to make a hole in either rectum or vagina very important to keep that still somebody's

pulling on my gown at the back there we go but now that that is the space okay once we find the space

it's a lot easier but it's just getting into it is is just a bit tricky sometimes yeah we can see

very clearly you can see it now good so just try and make this space much bigger now go down in

in between rectum and vagina as i say once you find it it's obvious but it's it's finding it

that's sometimes a little bit tricky try not to show me that sir so if you tilt the thing to the

right slightly keep your eye on the screen that's better that's better and then hopefully we'll see

it without getting that in the way we've just altered the angle of the um of the camera to

see this so that's good and i want to go right down on this i'm not going to just take quarter

of a centimeter i really have to take a lot of this to get right down to the pelvic floor

otherwise she won't have the symptoms from the rectocele corrected and she might not have the

symptoms from the intraceception corrected so i really do have to go down a long way

and you'll see in a minute what i mean by that now what i really want is that bit of the vagina

lifted anteriorly just come back with the telescope the camera can you get into that bit

it there with the swollen stick. That's it. Good. That's fine. Just keep it there. That's

perfect. Right. Now I'm going to hold the rectum. Last part. If I can twist this around

the right way. And I just keep some control on it there. That's good. And again, I'm using

the avascular plane to do this dissection. And I'm very cognizant of the fact that this

ultracision they say it's not as hot as scissors as diathermy but I can tell you

it jolly well is if you get your finger near this thing it's very hot so I'm

come this side all right as long as I can see the screen okay now come back in

down here sir that's good Sarah's our camera holder today she's doing an

excellent job. You didn't know you were going to be on television in Rome today,

did you? Come further in, further in. Now you might say how far do you go with

this? The answer is as far as you have to. I can't quite get down there, that's...

We're clashing with the instruments inside, that's why I'm working a bit hard

to try and find the direction. That's okay, we're getting there. Can I have a

tonsil swab please. I use tonsil swabs quite a lot in laparoscopic surgery and I use them in

particular areas obviously sometimes to stop bleeding but in this particular circumstance

to do a bit of dissection. So what you're going to see bring the camera back a bit

there's a tonsil swab going in and I'll take it right down to the pelvis okay this is the vagina

I'm holding on to, and I'm just going to use it. Just try and look down slightly. Just

alter the angle a little bit, sir. That's fine. I'm just going to use it. Come back

slightly when that happens. Okay, come in here, please. That's good. Be very careful

here, because that's racked to a wall. Using the cutting blade, keep it going away from

the tissues. Something bleeding there. If you get a bleed, the thing to do is to use

the tons whoops right you took your eyes off the screen that's why i said take it out clean it up

quick as you can a little bit of fog on the camera so we just clean that up and put it back in

straight away that's it got fred on it okay all right secret is when you're moving this don't

look at it just feel it keep your eyes on the screen right now there's a little vessel in here

when you get a bleeding vessel the thing to do is to close right in with the camera as far as you

course is to keep away from them which i'm trying to do dr parker that's why i go yeah sorry because

we we lost the connection for some seconds can you repeat the you you were just speaking about the

the most of this yes um down here i've got a little bleeder a little vein that's bleeding

bleeding or a small arteriole i'm not sure which it is i'm not going to worry about it i'm just

pressing on it come back with the camera i'm pressing on it with this tonsil swab and that

will stop it or most of it such that i will be able to get it in a moment so i'm just leaving

that there for the moment these are the paravaginal veins i'm sorry i'm afraid you lost the view again

i'm just going to clean the camera again really quickly good just to show you those because this

This is really important.

Right.

I know it's difficult this bit, so just try and keep the eyes there.

That's what I'm looking at.

These are the paravaginal veins.

And they really can bleed.

Go in a bit further if you can.

That's great.

Come as close as you can in there.

Now let's just have a look.

No, it's still not stopped.

stopped and just shows what a good blood supply it's got we're away from the rectal wall you can

see that there so it's safe to take this there i think that's got it it's got it satisfactorily

so back a little i'll just leave that swab down there okay now what i want to know switch this

round again swing it around to your side is how far down i am so i'm going to ask our assistant

at the bottom end just to take the swab on the stick out of the vagina and just

position with another colleague and just arrived to take part of this

operation but we've lost a signal right now. Nearly there. I'm Professor Parks and I've got a

lot of lot of vagina here but I'd really like a little bit more if possible I'm

just not quite happy with this yet just going to take this here I'm not just not

seeing that rectum so just just there this bit is quite finicky quite tricky

let's see where the rectal wall is so punk sorry to trouble that's perfect

We've lost the signal for a while, so we missed a part of this science part.

By the way, we swapped the commentator and it just arrived, so I can't now comment so much.

OK. Kevin, just tell me what's going on.

Now we can see you quite well.

You can see me? OK, fine.

fine. Okay, I just want to do a little bit more dissection here. I'm just not quite happy with

this yet. It's not quite sufficient. So I'm just going along the side of the rectal wall here.

Just need to bring this up a little bit. It's because of the adhesions from the previous

hysterectomy, but it's just not quite far enough yet. Now I'm just not seeing the anatomy properly.

Let's get a view. So that's anterior. That's the angular one, not this one. Okay, so that's anterior

like that just keep it there don't move this is vagina and all the bits anteriorly up there

this is all got held up because of adhesions so just come in here this is the bit i need to

release this is from previous surgery and it's just causing a little bit of distortion

come in a bit here that's fine do you have particular difficulty with the paravaginal

Yes, you can do. They can really bleed sometimes and they can really make a mess of things.

What I'm looking at here is trying to get rid of these adhesions here because that's distorting the view.

It's not quite anatomically correct yet.

I think the rectum is being pulled out to the side there.

Have you got the rectal probe in? Just show me again.

again. Okay, just push it anteriorly a bit and in. That's fine. Just keep it there. Keep

it there. Look up a little bit, Sarah. That's fine. Okay, now keeping the view like that.

Just come in a bit, please. Okay, now we're not doing too badly. Under there. Now keep

that view like that, Sarah, but just alter the angle of the camera angle. I'll show you

what I want just to there and keep it at that angle there if you can I realize

that's difficult I'm gonna take it right the way around it might be easier from

sufficiently far down now to start the the mesh introduction okay now I just

I'm going to press on the vaginal wall there, I just want you to tell me how far in I am there, can you feel my instrument, that one, how far down is that, I'm about less than two centimetres from the introitus of the vagina, and if you feel in the rectal wall now please, take that out, yes that's right, take that out, and I just want you to put a finger in the anus,

and feel anteriorly okay now I'm pressing there I can't see I'm about one centimeter or two

centimeters up the anus so I'm right down to the anorectal junction here you can see his finger

pushing in here and that's just at the top of the anal canal so as far as I'm concerned that's far

enough yes although prof we've lost the signal we can see quite well especially this moment of

the procedure okay good the finger just there very well yes good so what I'm going to do now

is to put the mesh in and sew it to the front wall of the rectum and then sew it to the back

wall of the vagina and then pull it up here and place it in the in the right place to staple it

to the front of the sacrum now we use a special mesh which is 17 by 3 centimeters so I have to

cut this I don't know if you can get the the camera on this you probably can't

you'll find that this will be exactly the right size okay

grasper again please another grasper another grasper just give me give me one

okay so this is going right in down here stay back with the camera and we've just

got to lie it on the anterior rectal wall. You're ready with the vicryl sutures. Okay, so I'm just

going to lift this here. Now come in with the camera a bit. We'll get it right down onto the

front wall of the rectum. So I just need to see this a bit more clearly. Just show me the rectal

wall. Put your finger in the anus, please. Okay, fine. So that's the front of the rectal wall down

there. And I try and get this in the right position as far down as I can. What kind of

prosthetic material is this polyester mesh it's sort of fairly soft you don't want anything too

hard otherwise you can end up with dyspareunia so there it is that's going to sit in the recto

vaginal space and I'm going to come back with the camera I'm going to stitch it in down there with

some vicryl sutures I'll take this out at this stage because it's just going to be in the way

I can tell you the next bit coming up is the difficult bit suturing is not too difficult in

inside the abdomen I know but suturing deep in the pelvis is very difficult because it's the

angles that are awkward so I'm just going to take this out and when I take it out take the camera

straight back so it doesn't flick on it okay so now we want needle holders with vicryl sutures

just looking at the there we are that's a little bit better isn't it the focus was out slightly

i think it's a bit better now now this is difficult because the angle is not good for

suturing down here um i'm my needle holders are coming in straight like that rather than at an

angle like that but you can't do it any other way you just have to accept that it's a bit like doing

a procedure with a up the rectum or something like that if you've got a needle holder that

doesn't release okay so the important thing is to have the angles right so you check the angle

that's not perfect let's adjust it get me another needle holder this one's not releasing

open it outside there we are that's the right angle now follow me in here sarah okay now this

This is going to be awkward. I might need you, Betty.

Hold this for me, please. That's great.

I'm going to release the rectum and use this retractor, if I can, to lift this up.

If I can get onto that, it might work.

Okay, Betty, can you hold that up there? Squeeze it tight.

Got it? No, it's dropped.

Have you got a ratchet, Grasper?

Take it there, if you can. Squeeze them together.

Look at the screen. You're lifting up like that.

That's great.

Okay, Sarah, alter the angle on the camera so that you're looking upwards.

That's right.

Good.

Right the way around.

And then come in deep down here as you can.

Okay, now you can see the problem.

I've got to push this port in again.

I'm just going to push the port in.

I'm right the way at the maximum extent of all the instruments.

Come back with the camera.

Okay, go in.

That's as far as I can push the suture holder, the needle holder, so that's where I have to stitch it in.

Keep very still now.

Now what you'll see me doing, I'm just going to push this one port in again,

is go through the mesh, and then take the wall of the rectum, but not too deep.

About there, that's perfect.

I need to see the tip of the needle.

Don't care what you do to show me.

push that's good and really need that other needle holder this one's gripping

all the time got it get the other one sorted out once we get the first couple

of stitches in it'll be easier okay just keep your eye on the short end perfect

easier I can tell you. We can assist to a real accuracy that you're doing prof. Well we're

getting there slowly the first two or three stitches are difficult but after

that it becomes easier quite see that so that's it okay and that that'll do it

they're just holding sutures these because of course in two or three days

this will be fixed like glue with all the fibrosis that's going to occur so

So we'll just cut this one out. Scissor, please.

So it's not so important to go very deep through the rectal wall?

No, no. If anything, I go fairly shallow.

As long as they just hold, that's all I want.

I don't want to go through the rectal wall.

Next stitch, please. Next stitch.

Yep, we're just going to clean the camera.

This is important so we see really clearly.

Well done. And needle holder. That's good. Thank you.

Thank you. Okay. Now again, we need to think how to do this. So just going to get the angle

correct first. Okay, so I've got a pretty good angle. I'm going to clean the camera

again. It's not good.

How many cases of this you do, Prof?

How many have I done? I've done about 50, I think. And I must say, I'm finding it a

very good operation for people with this condition. Really, the results are very, very good. It's

it's better than operate, just come back a bit with the camera, this mesh is too close,

to pull it out a bit, so that I can see right now, let's get under there, I want to see this

lateral pelvic, lateral rectal wall on this side, that's good, that's good, just come in down here

Sarah, sorry but that's in my way now, I have to just do it there, we're struggling with our

instruments here, because I'm clashing with the camera, but I just want to see under here, just

just to make sure I don't take too much of the rectal wall.

I don't even take the rectal wall sometimes,

just the mesorectum and the fat is good enough.

It's just something to anchor it.

So I'm going to go in about here.

There we are, that'll do.

We really appreciate how awkward it is.

I'm sorry, I didn't quite hear that.

We appreciate really how awkward it is.

yes it is but there we go that's a very nice stitch in there and as always if you put the

needle in the right position you can get a good pick up on that there we go I'm quite happy with

those scissor please so those are the lowest two sutures those are the difficult ones once we've

got those in it should be a little bit easier to put another two in on the rectum further up

because that was the fullest extent of the of the instruments it'll be a tiny bit easier now

but I hope anyway just going to alter the angle on the camera now so we can hold it there now

sir cuz I can look down stitch please other needle holder thank you okay so now we've just got to get

two more I put I'll put four stitches in total on the rectum and then two in the vagina and that

That should be sufficient.

So I always check that it runs nicely.

Now come down on the rectum here.

So something like that.

And I'm quite happy just to take the mesorectum.

It doesn't have to be sort of hard on the rectal wall or anything like that.

That's perfectly satisfactory.

This is quite clear.

Yes, I'm not worried about that at all.

That's fine.

Pull it through until we've just got a short end left.

And then we make a C.

I'm sure you all know you're suturing, but if you make a C on the left and a D on the right,

it's the easiest way to suture.

Good tip for anybody who's just starting off doing suturing.

There we are.

So that was the C.

You can see the C there.

So if I turn it round like that and I make a D and hold it in the other hand,

then it makes it very easy to go through the other way.

He says not able to do it.

There we are.

Very good, Professor.

okay so pick that up it's always the same whenever you're demonstrating something it never works does

it try and cut both because it looks a bit neater scissor thank you again just touch the strings and

then you know where to cut next stitch please you're doing really well here the the poor scrub

nurse has to cut these sutures get them loaded move the instruments and do it all 10 seconds

before I want it.

He's doing very well at the moment.

That's what you mean with the good nurse.

Well, we've got a very good one here.

He's doing an excellent job.

So there we are.

I've got a nice angle.

Just get this out of the way so that I can see.

Now I'm just looking down here.

Just come back a bit so that I can see the rectal wall.

It's lying on it.

Here's the anterior rectal wall.

I'm just going to grip this so that I can pull it back

and see where it wants to be

because I want it to be in a fairly straight line.

so that's pretty good there okay so there's the C 1 2 what is it it's alright one's enough there

we are so take it in roll it over pick it up and then I should be able to do on this side it's not

going to do it so I'm going to rotate it a bit more come back with a camera that's better okay

now go in is that the right one your movements are really fascinating well it's it's the only

way to do it but it's it's down a long long hole this i'm a long way away from it but it's the only

way to do it otherwise you can't get the angle scissor please should be a needle on that now

just give me a grasper for a moment now i'm just going to have a look with a grasper now just see

how far we've how much we've done okay so you can see it attached there okay that's to the front

wall of the rectum or the mesorectomy it doesn't matter which bit you get as long as it's attached

to. This is going to stick like glue by tomorrow. This bit I'm looking underneath so I just want

that pulled up there. Have you got the ratchet grasper now please? I'm just going to put a

ratchet grasper on here which will be a little bit easier for Batty to hold it up and then you'll see

a little bit better. So if I put that on there, there we are Batty, just hold that up like that

and rotate the camera to keep that right at the back like that. So you can see there that the

mesh is attached to the front wall of the rectum. Now what I'm going to do is attach it to the back

wall of the vagina. Stitch please. So that effectively we have a mesh sandwiched between

the two. And again, you'd think this might be easy, but it's actually quite awkward. I think

the one thing, the one message I would give you about this operation is you really need to be

able to suture to do this operation properly. Right, now it's not perfect anatomy because of

the previous because of the previous surgery but what i'm going to do is take a piece now i need

to see that bit there so you've got to be looking upwards need to be looking a bit more up switch it

right around the back this is where you need a 30 or a 45 degree camera now show me so i'm not

looking down the answer that's it that's good so i take a bite of the vagina like that at the moment

on the vagina yes I don't want to go through I just want a muscular bite if you like

and the vagina at the moment is being pushed anteriorly so now we take all the pressure off

that so that it can be released to come down here and the rectum have we got anything in at all now

that's fine so it should be able to come down and what I'm looking at is to see exactly where that

level is. So I take both bits like that, if I can get it, and I pull them tight and I see where it

wants to go, which is about there. So I'm going to attach this on here, on this side, to the mesh.

I need to see it. Okay, that's fine. Our problem is that the instruments are at the limit,

absolute limit, of where we can push. There we are. Now the difficult bit here, I can tell you,

is seeing the short end. Come back a little bit, and we'll just keep an eye on that short end there.

Okay, that's fine. Stay there, don't move. Just keep your eye on the short end for me.

And I'm going to do the same stitch here so that it'll slip down. I drop the needle because then

I can pick it up closer. There we are. And now I'll put a locking stitch in, come back a bit.

Again, I've got the D shape there, so it should be easy to go through, which it is.

The image is very clear.

Good. Good. There we are. That's one on the vagina that side. Scissor please. Okay. And one more

stitch. So I'm going to do one more onto the back of the vagina. And then we're going to staple the

mesh to the sacrum. And there's a little bit that you need to see there because it's quite important

how tight you make this. If you make it too tight, you get problems with constipation. Too loose and

it doesn't work it has to be just right okay so again just looking for the back of the

vagina just lift that up bet if you would no no don't leave it i want you to lift that's fine

that's enough this stitch is a matter of feeling really it is really yeah it's difficult to see

that's probably not deep enough just need to go a little bit deeper keep very no no you move betty

sorry just keep it very still there that's good actually it's not it needs to be deeper than that

it's not not quite good enough and i'm going upside down to get this and i'm fighting with

everything so i'll take that off it's much easier of course if the anatomy is normal

but post hysterectomy it's not normal that's good that's a good one that's just the right depth

the insufflators screaming at us because we're pressing on the ports to get the

instruments as far down as we can come back to watch the short end you said

that it must be push at the maximum yeah it is it is I don't mind if I get a

little bit of the rectal wall as well behind that's fine because it will

really put it exactly where I want it there we go so a C shape on this side

I'm going to do another one there to slide it down that's better just twist the string to get

it in the right position whoops slipped a bit that's fine I'll just put a locking stitch on

and a protact please now we've now got to decide where to put this mesh so what we do is we pull

the rectum out of the way. Another grasper. Just hold it there. Okay, and we'll place this mesh

where we want it to be. Now here's the sacral promontory here. So you see I measured it 17 by

3, and it's perfect. Absolutely perfect, because this is where we want it to lie. Now we want to

get it behind this part of the rectum, so we push the rectum well over there. This is how it's going

going to lie it's coming from the front of the rectum there to the posterior wall of the sacrum

here now that the secret is you want it taut but not too tight that would be too tight just go in

with the camera can you see how that is there that's too tight yes that will cause problems

of constipation but if you just put a little bit of a dent in it like that that will be about right

Okay, and so I'm going to put the ProTac in here through the suprapubic port.

So take this out now, take it off, Batty, please, release it first.

Look at the screen when you're doing it, that's good.

Sort of floppy net.

Yes.

You know, it wants to be reasonably straight, but not too much.

We're struggling just to get the grasper off.

That's it, take it out, straight out, good.

Now this comes in from the suprapubic port.

now there we are that's on the sacral promontory there that's a little bit too tight so i'm just

going to take it back a little bit and then start to fire it and then fully fire it that's one two

and one here just for luck that's what we need there we are that's perfectly satisfactory it's

not too tight but at the same time it will hold everything in the right position okay so i'm not

worried about constipation problems here that's about right now the last thing we

have to do is to close the peritoneum and get rid of that pouch of Douglas

keep that out of the way and we start off but we've got the V lock now suture

we're going to use a V lock suture which is a design of suture that's made by

Covidien I just want to get rid of this last bit there ultracision please for a

moment. This is the last bit of the excessive pouch of Douglas that we don't need anymore.

It's good. Let's put it with the other bit back here. Must remember to take both those out at

the end. So we're going to stitch this peritoneum with a V-lock suture. Now the V-lock has a loop

at the end of it, and modesty forbids me to tell you the author who designed that,

but it's described in the annals of the Royal College of Surgeons. And Cavidian very cleverly

have put some little barbs on the suture

so that it doesn't slip when you're doing a running suture.

Okay, you'll see that inside in a moment when I put it in.

Is that the long length or the short length?

The B-lock we also use for intradermic suturing.

Okay.

I haven't got the long one today.

I've only got the short one, so we'll see how well we do.

We might have to put a second one in, but if so, it's not a problem.

we'll just tie one to the other and then and then run it along so we start with this right down the

far end so just want to get the angle right that's not bad now I'm going to start right down here the

first stitch is always the awkward one so swoops can I have a grasp but just for a moment please

just see if I can hold it a bit more easily somewhere about there will do won't it so if

If we put that in, maybe to here, something like that.

Whoops, slipped, lost the angle on it.

I have to do this in two because it slipped in the needle holder.

That's good.

Little fimbrial tubes that get in the way.

Come back a bit.

That's it.

Well done.

Now I can change this now to the needle holder.

Now this is where you have to have good eyesight

and not too many glasses of lovely Italian wine the night before.

Which one, Prof?

I'm particularly fond of one or two.

The Barolo I find is very nice.

So we've got to get it through this little loop.

So I bring it towards me here.

Keep very still.

There we are.

That's through the loop.

When you can do that, you can do this operation.

And then I just pull that back.

You can see the loop.

It's nicely sliding on that.

And what I want to show you before I start doing this part of the operation,

I'll just pull this tight first of all.

This V-lock I use for intradermal suturing.

You do use it, do you?

Yes, I do.

Yeah, it's very good, isn't it?

Yeah.

But you can see the little barbs on the wire here, which will prevent it from slipping backwards.

We take a bit here.

It doesn't matter, this doesn't have to look very nice as long as it's functional.

It has to just close the space so that you have peritoneal covering and no mesh exposed.

It gets easier the further up you get, but that's good.

You see it's not slipping.

That's great.

You're doing an excellent job, Rob.

Well, we're winning at the moment, and we're about 10 minutes away from finishing this.

It's nearly finished, but I'd just like to show you the final result if we can, if we have enough time.

but it's looking good at the moment and this lady has had an awful lot of

trouble she's had six years of misery with this and she just got to the end of

her tether and she came to me saying please can you do something and I think

we can I think we have you see there that it doesn't slip that's great there

we go whoops again I just hold one end up so that I can do it much more easily

going to do it like that so as to shorten that bit of excessive pouch of douglas i don't want

too much of that left behind any need for a drain then no i don't use drains come back a bit sir

to get underneath that i don't use drains at all even even in major sections i don't use drains

i've given up years ago i used them for a long time and somebody asked me why i did it and i had

a three-hour conversation with them about the pros and cons of drains and i think we could do the

same this afternoon if you like we could have three hours to talk about them but in truth

there's very little evidence one way or the other and so i've stopped using them yeah i agree now

that's interesting because that's the bit of spare i'm just going to stop here for a minute because i

might just want to take a bit more of that patch of douglas away there so i'll just leave that

needle. Can I have the ultra-cision a moment and a grasper? I'll just show you there's a little bit

of spare redundant loop pouch of Douglas here that I might just want to do a bit more Douglas

ectomy on. We'll have a look at it and see, but I think it deserves to go. Professor, going back to

the size of the prosthesis, that also doesn't matter the height of the patient? No, it doesn't

seem to matter i cut them all 17 by 3 and every single time it's pretty much perfect

just got to watch the rectal wall which is just there can you see it yes there it is there's the

rectal wall but we're just taking this excessive bit of pouch of douglas off so i don't want to

leave too much behind because she did have an entra seal as well you see so i'm just trying

to prevent that happening again there we go put that over with the other bits so that's the douglas

vasectomy, all that stuff there that's got to come out, needle holders, and we just carry

on with the closure now. We've nearly finished. This should look a lot better in a moment

once we've got that Douglas pouch to a more normal shape. We've already gone through that

side, so I want to pick up the other side. So it's just under here somewhere, underneath

there, so that it doesn't lock. So we don't need to lock these sutures with a V-lock.

it's does it by itself I need to hold it further down so I've got room to maneuver in your hands

prof you're making a difficult procedure very simple as it looks like well that's very nice

of you to say so but we're on the easy bit now this is much easier than the most of it has been

but this is the good bit now I like doing this bit it's what we call the home straight that's

That's right. Sarah's just reminded me.

But it's important to get this right, otherwise, again, you get distortion of the bowel with problems with constipation.

And you must, of course, cover the whole of the mesh, otherwise you'll get adhesion problems.

Prof. Parks, when have you realized to do this kind of procedure, making the floppy net, let's say?

Well, I think some of the people who did it at the beginning, I mean, I started pretty quickly after Andre Deux described it.

people were saying that if you put it too tight you get problems with constipation

and I had one patient who did get problems with constipation and sure enough the mesh was just

a bit too tight and I had to go back in and release it and put another one in and that was

really difficult I can tell you but it's it is a fact that they can be too tight so I think it's

worthwhile just a little bit of laxity it doesn't have to be very much as you saw oh that's clever

winning at the moment we're doing okay must be the nurse yeah i think so well not my fault

it's always somebody else's fault isn't it thank you very much that's super okay so here we got

another one for me to make a fool of myself with again so we'll just bring the whoops see all the

nice barbs on it and there's the loop yes that's the one we have to get so i'll just start this

put one stitch further back to try and lock that loose end. I won't tie a knot in it. I think it'll

be sufficient just to pull it tight, actually. That should be all right. Keep that port out of

the way, please, Patty. So again, we just continue along here. We've managed to get the proctogram

available for you, so as soon as I've finished, I can show you that if you wish to see it.

yes please interception okay I'll show it to you at the end now I think that's

going to lock if I do that so I need to come back a bit sir need to go

four more stitches I think and we're done it's very smart useful they will

lock oh I think it's terrific it's really good isn't it and it takes much

much less time to do this bit of the stitching when you've got this.

Excellent job, Prof. Very nice and neat.

Oh, we're nearly finished. I think this might be the last stitch. Just pick it up there

to do this. There we are. So we just bring this through. So we've got a little short

end there. And again, it's the old principle of doing it with the right angle on the stitch.

Now, what you want on this side is a C, so I turn that and pull this towards me and turn

it over.

There we are, that's a C. And that way you can go through the loop very, very easily

like that.

Pull up the short end, don't want that appendix epiploica in the stitch, so we'll just pull

it out, catching on the barbs of the V-lop, that's better, there we go, it's absolutely

fine.

and a D on the other side. The only bad thing about this is the barbs do catch a little

bit when you're locking these sutures. That's fine.

Okay, now we're going to cut that out. I've actually already cut one of them by mistake.

little bit. I don't like to leave too much stitching around. There we go. Now, grasper

please just need to get rid of those bits of tissue there's one bit out and they all come

out through this 10 millimeter port pretty easily two three there we are now just to have a look

around now and check it it looks a little bit more anatomically correct now i'm happier with

that it's all covered there's no bit of mesh looking through there it's all clean and tidy

We know that the rectum is well held up, so we can now place the rectum back in the normal position, into the pelvis like that, and that looks nice and neat.

This lady will go home tomorrow morning.

She'll be eating this afternoon.

She'll have lunch today with a nice bottle of Barolo.

Table flat, please.

I will join her.

she'll go home tomorrow morning good are you waiting for the first now the last thing i'll

show you is just the last thing i'll show you is just how i close the ports just hold the camera

there please i'm sure everybody has different ways of closing ports i don't close the five

millimeter port because there's no need but this 10 millimeter one i will close with a straight

Vicryl and then a needle endoclaw thank you somebody reminding me what it's

called okay so we just put that in there and I put a finger over to stop it

losing all the air just come back a little bit I think we're up here

somewhere. Prof I wonder how is the expression of the facial expression of

of this patient for the first defecation.

I think she'll be very happy.

Sure.

Probably the best thing that's ever happened to her.

Sure.

Second best thing.

What is the first?

I'm not telling you.

Okay, so we pull that in like that.

Okay, now the endoclaw, please.

Try and keep that.

You need to...

Hold that, Matty.

You need to pull the port back a bit to give you a chance to see this easily.

That's better.

better. Now we come in on the other side of it, just a bit below and a bit lateral. That's

good. Try and pick this up. I'm working back to front now, of course, because I'm looking

at it backwards. I have to keep saying to myself, left is right and right is left. Oh,

come on. God damn it. Usually this is very easy. There we are. Got it. So we pick that

that up, and I've dropped it just at the vital moment, have you got a clip, you got a, yeah,

no, I'm going to do it again, I can't see that, unfortunately I've just dropped this

just at the critical moment, so I'll have to do it again, so we just go back in here,

pick that up, this time, hopefully, there we are, we've got it, and now we just tie

a knot on the outside, and that closes the 10mm, 12mm port, I always close the 12mm

ports because I have had many years ago two incisional port site hernias both in 12 millimeter

ports I've never had one at a five millimeter port so I don't I don't close the five millimeter

ones just the 12 millimeter ones and there we are that's the operation done excellent

okay these ones these ones we can just take out and you can see gas off please and we just look

at them to make sure that there's no bleeding which there isn't and then we can let the air out

and as far as i'm concerned this operation has finished that's the net result total bleeding

about three mils i think everything back to normal everything okay at the top nice clean liver not

well used and there's normal gallbladder and everything else so everything's fine

and I'm taking the camera out now I'll show you that proctor gram if you like

yes please yep okay we'll try and get it on the

screen which screen will it come on to which which screen are we going to get

the proctor gram on what I really need can you aim the wall camera at this

screen and put the proctor gram on here if you can in Rome and just we're just

organizing that proctor gram to come on our main screen here and then we'll put

put the wall camera onto the screen so that you can see it okay and then I'll

just take you through it it's a very good proxogram she has immediate here we

are can you see that yes no not yet okay okay well we've got it on the screen so

we're going to organize the wall camera and the wall camera is going to come

down and look at it down here can we move this out of the way out of the way

We can see the mist that is playing with the patient.

Okay.

Now, can you see the proctogram yet?

Yes, almost.

You can?

Yes, yes.

It's a bit oblique, the view.

It's a bit oblique, the view.

Can you zoom in at all?

I think that's about as good as we can get.

Now, can you run the proctogram now?

Oh, yes, that's marvelous, John.

I didn't realize you were here.

Thank you.

Here's the rectocele at the front.

Can you see that?

Very well, Prof.

We've pulled the rectum up, we've fixed it to the rectum and vagina and stapled that to the sacrum.

So that will no longer happen.

She won't sink down there.

It should stay up here.

And we've foreshortened the pelvic floor so that even if the small bowel comes down, it won't get right down to there.

It may get to here, but that will not cause her any symptoms.

So I think that's the end of our operation.

And thank you very much for watching.

Prof, that was jolly good.

Thanks very much for your mastery of surgery.

You're very welcome.

Very, very nice.

We enjoyed it.

Thanks very much.

Good.

Well, thank you very much for being here.

We wait for a binge of Barolo.

I will look forward to it next time I come to Rome.

For sure.

Thanks again.

Okay.

Bye-bye.

Yes.

You should also say thank you.

Sudha has an anesthetic.

She's been very patient and very quiet all day.

and the rest of the staff in the hospital here in the theatres,

but also to Stryker, who have been very good.

They provided the link and the camera systems here,

so I think they should get recognition for that.

Thanks very much, guys. Thank you all.

Thanks to everybody, and a special hello to the nerds.

Bye-bye.