F. CORCIONE

Position, this is a good idea by Michel Gagné for the side organs, spleen, adrenal gland,

kidney, and so on, because in this position, we are very, very close to the spleen in this

case, the trochars are very very close to the spleen. The scope is almost

perpendicular to the spreniculus. In the past I performed almost 100

cases of sprenectomy with the scope in the umbilicus. So can you see the

difference between the vision that we can have in this way and the vision

that we can have in this way and we put the fourth trocard along this line that is the

costal arch the five millimeter for the left hand of the sergeant and another trocard of 10

millimeters for the right hand of the of the sergeant and the fourth one very laterally

for the assistant, and this is standard position, standard of trochus, standard position of

the patient, and the big advantage is that all the bowel slide down, and we don't need

to retract the bowel, we don't need to retract the stomach, because as you can see, anything

is retracted by the lateral position.

because the spleen is a lift in his natural position and I have the right

way to dissect the vessel of the splenic ilus in order to perform see

clean the scope please and as well yes as well goes for me

are you working in 3d or 3d yes yes we had the first operative room in 3d four years ago

and we were lucky because the 3d is not a option is a really advantageous for the sergeant

because the vision is fantastic.

So I would like to show one small detail.

These vessels, vein and artery,

is coming from the left gastro-pupil vessels.

And I published recently an original technique

about the near-total splenectomy.

I call this near-total splenectomy

Because when you have a big mass, a big cyst of the spleen, it's not rare.

You can perform the near-total splenectomy, which means that you have to dissect and you

close all the splenic vessels and you leave in place only this one that is coming from

the left gastro-pupillary vessel.

At the end of the operation, you can see here the good vascularization of the inferior part of the spleen.

And you go inside in this line to dissect the spleen to preserve this one.

Of course, in the young people, young guy, that need about the function of the spleen.

In this case, do you perform a total spleenectomy?

It's a hematologic pathology, so I need to perform the total splenectomy, of course, only for the cyst.

Sometimes also for the spherocytosis, some hematologists that work with us ask me to perform the near total.

So, I go, as you can see, from down to up, looking for the short vessels and trying to

reach the lesser sac.

And to do this, the best solution is to perform a traction on the stomach, look, and now through

this way, I will reach the lesser sac.

And this dissection, the ultrachisium, as you can see now, my dear Guido, is very, very useful

because I have the video of my whole experience.

I performed the first splenectomy in 1992 with the patient in a supine position without ultrachisium.

And it was a long operation.

It was a long, at least three or four hours.

Another advantage of this position, and I published the results in another paper in

a surgical endoscopy 10 years ago, is that you can see very, very well the pancreas in

order to avoid to injury the pancreas.

In this position, in our results, we had no pancreatic lesion, no pancreatic complication.

In our first experience, we had three abscesses from pancreatic fistula.

My goal now is to identify first the artery.

is just to put a clip in order to have a good devascularization this is my option the 3d help

us to see very well and i am working between the artery and the vein look i don't know if yesterday

you were you were in the in the room i performed a very rare operation the dunbar syndrome and

And I worked with the celiac trunk to mobilize all the vessels of the celiac trunk.

I think it was very interesting.

Yes, I know. I have seen it.

Okay. One clip. Only one clip to close the arterial...

Flow.

Flow, yes.

In order to reduce the vascularization of the virus,

in order to have a good opportunity to dissect in safe way also the vein that usually is very very

large so now I go to mobilize the spleen posteriorly difficult and I go now okay

Also, these vessels, I think that are not of the ilus, it's a terminal, the pancreas

is just behind these vessels, and now I go on the vessel of the ilus, as you know, the

He loses very, very, there are a lot of variabilities, bipolar, but this is the artery, and the vein is behind.

And the artery is already clipped, so I have no problem to dissect the artery here.

All the pancreas there is preserved.

so it means that we did not clip the trunk of the splenic artery and there is

no there is a something more but the ischemia of the spleen is almost

complete very very close okay now I found I look for the right space between

Between artery and vein.

Guido.

Yes, tell me.

It's very strange to speak English after...

Then we can speak Napolitan, Naples.

My sponge helps a lot to clean the operative here.

I am on the pancreas still.

Okay, now I'm very, very close to the spleen.

in order to avoid the pancreatic lesion okay and now after the section of the

artery you can see how it easy to dissect the vein because there is no

tension okay all the other spleen now is completely

scaling the vein so now I'm quite sure that all the artery are clipped I have

this small clip disturbs a little bit you don't use the ultra scission for cutting the vein

you cut no do you prefer to put those clips in any case in any case but it because with the

ultra scission i i can put only one clip is is incredible that when we perform the

called cystectomy we put always two clips on the cystic artery because we cut with the

sheaths and when we cut the splenic artery we put only one clip.

The first recommendation in the laparoscopic approach was to put always two clips.

Look the pancreas is very very close to the splenic hills as usual of course.

Okay.

I don't know, in several operations, like colon, like, of course, colicistectomy,

we did not, yes, by Paul, we don't put the drainage.

the drainage for the spleen for the spleen we put always a drainage okay

on the spleen what do you think about the drainage Guido? well it's a good

good operation, so

perhaps you can

avoid to put the

drainage also for the splenectomy.

No, no drainage.

We will see. In this case,

it depends from the operation.

In this case, I think

it's perfect. Okay, now

we remove the trocar

under, yes, under vision, yes.

And

I will leave with

Ernesto

and

And, okay, okay.

Mercerization, please.

And I'm ready for the second operation.

It will be more interesting for you, Guido.

Yes.

What is the second operation?

The adrenalectomy.

Ah, okay.

Diabetes?

In which position?

The same.

Ah, the same.

I put the same, the two operations, one after the other one.

This is a 30-minute operation.

It has 45 plackets.

Mr. Lett, cut here.

Okay.

Okay.

No, no, no.

Give me the eye.

Eye.

Close the eye.

Cut.

Cut the bag.

Okay.

Okay, I will leave Ernesto to joke with this.

Thank you, Ernesto.

So Guido, in three minutes, we will say again for the other operation, okay?

Okay.

Three minutes, only three minutes.

It's a pleasure to follow you.