F. CORCIONE RESEZIONE ANTERIORE DEL RETTO VL 3D

Lesion of about 4 cm with bleeding, important bleeding, and at the histological pattern of this lesion we found a lesion like adenocarcinoma.

The patient performed also an abdominal CT scan where we found a cystic lesion of the seventh segment of the liver

and a cystic lesion of the right kidney of about 5-4-3 cm.

On the bowel we found at the junction of the recto sigma and parietal thickening by an heterogeneous lesion along the left colon until the superior rectal area.

And we found also a chronic colitis from along all the left colon.

In this case, we propose a procedure like a laparoscopic anterior resection of the rectum with a 3D system.

Allora, se mi date indicazione, Stefano, in English o in Italiano?

Franco, welcome back! Still in English.

Ok, so, performance of colorectal surgery.

Did you hear the presentation of the case?

Big Neapolitan woman, she like a lot the pasta and pizza.

And in this case we have to perform the right...

So, look the importance of the... Do you see the laparoscopic view?

Yes, yes, we can see.

Yes.

Very, very clear, yes, here.

Of course, we try not to injure these vessels.

Ok, and the difference between Radicruz, look at the vessels, look at the troca, the risk is my life, so for this operation she is erotic pathology, in our country we have a lot of this pathology related to hepatitis C,

And we put the fifth trocar on the line of the sorapubic incision.

Okay, so five trocar for this technique.

But I'm so sorry, but I will repeat the same step of before.

So perhaps for someone who is now connected with us,

could be very interesting.

For you, I don't know, I don't think so.

So, I put my epiplon under the liver, fibrotic liver, valid, valid, grasp the yellow, and yes, pum, pum, down, ok.

Ok, and now I start again, as before, with the mobilization of the sphagnum fracture.

I go to the, I repeat on my landmark, that is the superior margin of the transverse colon,

and I go from medial to lateral dissection in order to reach the lesser sac.

I think that it's not important because if you follow this line, you will reach the Lesser Sack without a problem, and this is important for the mobilization because, ok, now we reach the Lesser Sack.

Yes, you can hold

laterally.

Ok, well, so I go

always in this

landmark, that is

the merge of the

transverse colon from right

to left. Everybody

now, I think,

is it the time to lunch, for the lunch?

No?

No, no, no, don't move.

Now we show you the posterior world.

Yes, but, you know, it's

all the time here, it's a very quick

lunch, so people is grabbing something for eating, coming back in the room, so it's...

You don't use reverse Trandelenburger, no, only flat position.

Now, yes, I forgot to tell you about the position, the nurse is in front of me, the assistant

The assistant is between the legs, the camera is on my right.

Now I stop because I have not the force to continue here because the trocar is very far

from the spring flexion, but I reach my goal, I went into the lesser sac without problem.

Now we change the position, the assistant take the mesocolon and pull up, push up, ok.

Laterally, laterally, the patient, the table, move to the right completely.

You have a dilatation of this bowel.

OK.

Impositor and derby.

OK.

Stop.

Lanzare tower.

Now the cameraman changes position.

He holds the scope.

No, no.

He changes position from my right.

He move on the left side.

and in order to avoid the tube and now we are going to look for our

landmarks. The landmarks, the first landmark is the trice ligament.

We have to mobilize the bowel from this attachment, embryologic attachment.

This is important to allow the bowel to move on the right more.

At the same time, it's important because if you mobilize the bowel,

you can see very well the second landmark, that is the mesenteric vein.

And we start always with the vein because I think that is the best solution

to avoid, to damage the post, the retroperitoneal structure, because you can identify very, very easy way the dissection, the right layer of dissection of gerota fascia from the third fascia, the embryologic dissection.

I insist for this dissection because this way I can move the bowel on the right better way.

OK. We go to see the vein that is always laterally to the first bowel.

In this case we don't see very well, so we have to give a look to identify the vein.

I think it is this. OK. So I am sure that now we have the vein here.

So I ask to valid very good sergeant coming from South Arabia.

And now we go to identify the right layer of dissection between told gerota.

I think that we have here the lymphatic duct of rotolo.

The key point is to identify here the right layer of dissection between gyrota and told fascia.

So I recommend the head with the blood dissection.

Even if you have small bleeding, it's not a problem, but in this way you can identify without a problem.

Like I showed you before, the standard technique for the left hemicolectomy is always the same.

In this case we will perform the partial mesorectal scissor.

And now I go from up to down, from medial laterally, dissection.

It's not English, but repetita juvant, I think everybody can understand what I mean.

So if we repeat something always in the same way,

always with the same concept, you can give to everybody the opportunity to understand what is our strategy,

because this is a strategy, it's not the only strategy that all the world use,

because everybody use a different technique, but in my experience I changed several times

Before to arrive to this standard technique, and there are a lot of years now, use always the same, ok, to identify the artery, we know that it is under the cord of the vein, first, and then is between this cord, the cord of the artery, iliac artery, and this woman.

This woman is not easy to identify because of the fat tissue.

We go to join the two layers and we open this space.

In this fat tissue we go with our ultrasound to identify the artery.

We don't see the artery now, but we are quite sure that it is between this line and that line.

This is the reason that I prefer this kind of dissection.

Good demonstration that...

Yes, you reached the inferior mesenteric artery.

There are no big lymphocytes pushing around, and this is the mesenteric artery,

and the left colic artery is coming there.

The artery is there, the artery is there.

Yes.

Only in this moment I pull up with my hand the mesocolon and I try to identify the right plane of dissection.

line clean better please

ok

these nodes

are under the artery

I think that it's enough

to keep the old tissue

to keep it apart

ok

are you giving separately from the spaceman

to the pathologist?

essentially

in the fat tissue

We continue pushing up the told fascia and we try to pull down the gelato fascia.

It is very easy to go in the wrong way in this case because of the fat tissue, but your landmark should be always the same.

ok, I will not identify the lower edge of the pancreas here, but I am quite sure that now I am under the descending column, so I just finished my dissection, now we go to the pancreas, it is there, here we are, so only at that moment we go to cut the mesenteric rim,

That is our guideline to identify the artery and to identify the right layer of dissection.

I told before that sometimes there are some vascular crunch of the left colic, of the middle colic artery.

So we have to pay attention because I don't see anything here.

Ah yes, this is the artery and this is the vein.

So, ok, this is the artery, the colare. Now we have to see this small artery. It is very useful to our vascularization. The two veins are there. Ok, and this is the artery.

The problem is that all of this artery, this artery is coming from the medial colic artery, is a connection with the left colic artery.

So we have to be sure that we have left colic artery because this effect tissue is not easy to clarify if we have...

In other words, we have, we need to cut this artery because we cannot have the tension free anastomosis, but I am, I put a clip, but I don't cut.

I put a clip, and I would like to take advantages by technology, and we will see with the green in a few minutes, with the green in the question.

Do you understand my strategy? I am afraid to carry...

Yes, you want to be sure.

I think that you have seen that it is more easy if there is the gas that allows you to identify very fast and very well the lesser sac, and we go under vision from medial lateral dissection in order to pull up the vasocolon without the danger of the pancreas.

Even if we have these vascular problems, these demonstrations you can go ahead without risk for you and for the patient.

If we need about this small artery, at the end we will have the section of the vein a little bit down.

Ok, now I think that it's enough, the pangas is there, without the lesion, the mesocolon is up.

Ok, we go laterally.

Now you complete the splenic flexure takedown. Ok, from lateral.

We are going in the room to prepare the test to the green, to be sure that I can cut the small vessels without danger.

is one of the good indication of the great test, I think, because if that small vessel

is the only connection between the medial colic artery and the mesenteric artery,

because there is no left colic artery, you have the high risk of very important postoperative scan.

We had, of course, we had very important scanning, and there is a video that I show always when we speak about the post-operative computation.

So, my dissection allows me to go in this layer without risk to injury the ureter or other retroperitoneal vessels.

Everything is done posteriorly. As before, I will change the position of my instrument in two seconds.

OK, now I change. And Walid will keep the grasp always yellow.

And I have now two hands to complete the mobilization down.

And look, this is very important. I don't go in this way, laterally.

I go very closer to the colon, like the detachment that I did before.

This is the right way to avoid any injury of the spleen that is always very far in this kind of dissection.

And I am quite sure that the pancreas is covered by my sponge,

so I cannot have some injury of the pancreas, of the lower edge of the pancreas.

And now I will see my guideline. Here we are. This is my sponge. It means that the pancreas is down. I can go here without problem. Laterally to the colon. Laterally, I'm on it.

This ultrasound coming from this trocat, as you can see now, is very perpendicular to the line of dissection.

It's closer, so it's more easy to continue this dissection instead of staying in the old position.

Franco, there is a lot of foggy inside. Can you try to clean a little bit, opening a small chocker?

For us it's perfect. You see a lot of fog? Ok, now I try to avoid this.

Yes, it's the fog from the device, of course, but...

In Naples there isn't a fog.

Only blue sky!

The pancreas is completely free, the posterior wall of the stomach, the genota fascia, and the spleen is always far from the eye.

So, now I would like to change the strategy. It means that I have the opportunity to check if this clip has created a vascular ischemia, and changing for one minute the scope, try the green please, we will dissect it after, the vascular ischemia.

We check again at the end, of course, but in this way I can...

E la rettale è chiusa.

Go, go, Paolo, you are ready?

Sì, sì, complimenti, due di voi. Vai.

We are looking outside.

Ok. Go with the green, please.

Ok.

Ok, 20 secondi, 1, 2, 3,

It's green, it's green, it's perfect ancora un po',

I would like to see very well the...

Ok, now it's very... now it's green.

All of it is. Now it's green.

Ok, it's good.

Mi cambiamo l'ottica, ok.

So, now I cut that small vessel,

because another way it was...

it could be impossible to have

the tension of the anastomosis.

Go, go, the vessel.

Mamet. OK.

Thank you. Thank you.

Now, we go laterally

to finish with

lateral dissection.

The spot is always inside.

Mobilize laterally as

I can. Identify

the space of the

previous dissection. Always in

embryological plane. OK.

Probabil opening the pelvic peritoneus you can identify a little bit better, starting from the right.

Can I ask you what do you think about using 3D technology for this type of surgery?

All the surgery in 3D is a key innovation. It's not a play.

I think that we had a lot of advantages using this technology.

Overall, for some specific operation, we don't need for the cholecystectomy, of course,

but for all the advances of laparoscopic surgery, I think that we have a lot of advantages from this device.

We published our experience in the mesorectal schism.

Volit, here, please, a little bit here, here, here.

Help him, please, help him.

OK.

Lift.

OK.

Volit.

Now we approach posteriorly the mesorectum.

OK.

It's there.

So it's not too low, I think that, I think that we don't need, it's there a little more, it's not at 12 cm, I think it's a little behind, so, ok, it's not too big to me, I think that it's at least 15 cm, ok, ok, ok, in fascism, in fascism.

Is that good? Yes? Change here? Here?

Ok, perfect.

We're approaching the mesoretto fascia.

Always the most easy dissection.

This is blunt dissection.

You can pull Antonio.

Spoon. Another spoon, please.

Lift. You need to be on the right.

Franco!

Franco!

Are you using also a uterine manipulator?

I prefer to put a stitch, but it's a good option, the uterus manipulator.

Usually, I put a stitch coming from up from the abdominal wall,

right stitch, keep the uterus, and bring it in a fixed position in this way.

Okay. Thank you very much.

Thank you. But it's a good option.

I need an endoscopy because I don't know if the tumor is very big, it's like a big tumor, yes, amicare.

I would like to check the level of the cancer.

The vaginal is up, the colon is down, and you can follow this as a plane.

Look how useful this hand is for a good exposition, and at the same time to avoid to bless the mesorical fascia.

This comes from Bill Leard, the Pinot technique.

Ok, now I would like to check with endoscopy the level of the section, in order to avoid to go more down than we need.

Franco, are you ready for a colonoscope check?

My impression is that your tumor is very deep in the staff, a little bit lower.

Are you using a CO2 insufflator?

No, sorry, what did you say?

Are you, for the colonoscope device, are you using the CO2 insufflator?

But it's only rectoscoping.

Ah, ok, ok, sorry.

Yes.

Amicare is our proctologist, is a rigid...

Rigid one, ok, ok.

We look for the liver.

Go, ok?

I think that we are good.

Right?

dai, col dito che si senti, dai, questo è direttivo, dai, il ciaso basso, ok, vedi un po' se questo livello qua,

il tumore, questo è il tumore, vedi un attimo, dai, questo è il tumore, arriva qua,

I feel that there is something there, so this is the reason of this endoscopy.

Ok, and how is far from the anal verge?

Ok, ok, ok.

Qua vedi qualcosa, here, si qua, no, there is nothing, so we can stop here, qua, eh, c'è tumore, si, so I feel very well, so, eh, no, no, tumore qua, esci, dico qua, qua, esci, esci, esci, esci un po', ecco qua, qua dove io ti tocco, qua, no, ok, no, ok, allora we can stop here, the tumore is, yes, is, is, is this one, only this one, ok, so, keep it there,

You ask this, please?

It's not in your head, no?

I don't have a problem.

A lot of fog?

No, in your...

Ok, not in your head.

Ok, thank you.

Look, there is one of the two branches of mesenteric artery.

So I use the slow function, more effectiveness, as you can see.

struffoli.

What do you prefer?

My favorite one is the pastiera.

Ah.

Yes. Only in stupid years,

I know. Any time.

Ok. Almost finished.

A couple of...

The fifth trocard,

the soraputic trocard,

is very beautiful.

It is very useful for us,

this woman, but

like the right hemipolite,

We put this trocar on the line of the soraputic incision, so at the end we have only four trocars.

Are you using also in this case the band to suspend the colon preparing the staplers?

Yes, like in the right colon.

At times when I have a very low dissection, I put this loop around the sigmoid segment, but in this case I think that it is useless, because the dissection here is most evident in the right amicolectomy, it is more easy to perform, and I don't need in this case.

Sometimes we use for diverticulitis because there is another kind of operation as you have seen.

Ok, go, stapler. Yes. No, no.

Another advantage of the suprapubic trocar is that we can use the stapler coming from up that is more direct, always fortified.

Is this coming from the suprapubic trocar?

Oh, why?

Always another one.

Here, if there is almost nothing,

but I would like to be sure that everything is included in this structure.

OK.

See, we clean.

Always the same.

We are ready for the anastomosis.

OK.

So, I hold this part of the colon.

And we go outside.

Vistri.

Luce.

Basta.

Venite prendendo.

Ok.

Ok.

Luce.

Retractor.

Retractor.

Passare un bel cavolo.

Ok.

Marco.

Franco, dimmi.

Exacto.

Do you have a computer?

In front of you?

No.

No.

No.

No.

No.

No.

No.

No.

Pardon, pardon, sorry.

I'm in the backstage, and there is someone who brings me the questions from the web,

because, you know, there are some channels that are living on the web,

and questions are written. They bring us the questions and we will ask to the surgeons.

How many surgeons are connected now?

I have not this information, but I will ask.

Ok, ok, this is good. This is our point. Ok, qua. Ok, the vein is well identified by the clip, but why Diego left me? Why Diego? Ah, sorry.

franco franco ok the numbers of the surgeons connected by web will be available tomorrow

ok i think that tomorrow you will be there because palazzini pay a lot to have you

spesimen,

attention is

hepatitis C.

The end, please.

don't finish with this case.

We have another case, another column.

Wow!

It's right

or left?

Of course.

I speak left, not right.

Ok.

But tomorrow we will change, don't worry.

Completely.

I am a little bit nervous.

Why?

It's very interesting, you know, also when you can follow someone who's trying to do always the same act, and it's important, because you know how someone can follow a strategy, so it's really interesting, because when you see someone only follow one procedure, it's okay,

Ok, but when you see someone with more than one and you can see that the strategy, the act are the same, you really can understand that there is an idea to follow all the time.

Thank you, but exactly this is the reason that I decided this time, in this edition of the Palazzini Congress, to have one day only for the Colorado Sages, in order to repeat some steps, to give some messages, and to improve the knowledge of everybody.

green if our vision of the color is right or if there is some ischemia

insuffriamo insuffriamo dai medium un po di renderebo poco no goes inside ok stop

Yes. Ok, the green, yes, the green lava. Yes, yes, we are ready. You can start with the green. Now we will have the scope, the laparoscopic vision. Ok, this is your bowel. Ok, very, very, oh, un attimo.

Acqua caldo.

Continui.

Finisci, mi discopierai.

Una galzina.

Forse un po'.

Acqua.

No, se c'è l'altro, forse non l'avrò.

Fuori?

Si.

Ok, stop.

I want the other camera.

No, nipo l'aria.

Zena fuori.

Vai, girita.

Lo hai.

Lo hai.

Yes, yes, yes.

Just step.

Perfect.

You see the...

Yes.

Perfect.

The suture come from up.

In this case is a vector.

Ok.

So we go to check

now from up to down

the right position of the tether.

We have to close

always the same space.

The space is this one.

Look, the bubble is almost ready to go behind.

First, check that the tegna is there.

Go down, go down, go down, go down, go down, go down.

You asked me before if there is a difference with the 3D scope.

This is a demonstration.

I think that now we are looking with the 2D scope, there is a difference between the first one.

You can appreciate the difference now.

Look, the importance to close this defect, and now it's difficult to close it in another way than it can be.

Ok, now, 5, 2, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, good.

Also in this case we perform only the blue test, blue air test.

Ok, go.

Blue.

Good arm, good arm.

Look, the blue.

Maria.

Si, si.

Maria.

Si.

Did you see Marco?

Yes, very well.

It is some blue on the sponge. Looks to come from the up and left side.

Yes, I put a stick here.

Ok.

Thinking about the idiostole in this case.

Franco.

Si? Yes?

You don't think it can be useful also to do a bubbling test?

babbling babbling just some put some water in the pelvis and a yes at the blue yes

si

and then with the bubbles

so we did not see bubble

we see a little bit of blue

have a chance in my scope

free disc scope

why do change

intraoperative problem

but

this is the reason that we

now we check again

with air

and blue always

this is a 3-O Viqoil

Yes, bike wheel 3-0, 3-0.

Change the sponge.

One.

Give me another one.

Another stitch, perhaps, before.

Give me another stitch.

Another stitch, yes.

On the left.

On the left.

Go down.

Go down.

Another stitch, please.

Yes, give me another stitch.

Ready?

Yes.

Thank you.

This is clicking.

Which one?

This one.

This one that we are using?

It's a 50 degree.

It's the 2D, it's the scope that we need.

Ah, ok.

It's another scope, it's another 3D, unfortunately.

So, to go faster, we did not change, and now we pay, I pay, because in 3D it's better to put a stitch.

If the patient has tomorrow forty-five temperatures, if she has a little pain, if she will have a little pain, if she will have a little difficulty to go up, scanner and inostomy.

For instance, only, for now, only, very big, my, and, ok, now, I leave about to finish this operation.

You, you, differently from the other one, you drain this, this one.

The, the, the, ok, you, you drain, yes, ok.

Yes, yes, ok, now, the, the,

Joanne? Joanne, please.

Where?

Out.

Anti-trend member position?

Yes.

Please, anti-trend member position.

Ok.

Should I be anti-trend member?

Yes.

I am.

Ok.

Now we are

waiting for the last operation.

Ok.

Ok, thank you very much, we really appreciate it.

Thank you, thank you. It's a pleasure to share with you this experience.

Ok, how long, in how long you are ready for the last, for the fourth surgeon?

We had a problem before for the patients, so they are still going to change now, so I think half an hour at least.

Half an hour, ok, no problem, ok, thank you very much, see you later, bye.

Ok.

Preparare.

Preparare.

Porpeche, please.

Salvatore!

Salvatore!

Salvatore!

Salvatore!