TranslatedVideo.mp4

Welcome to our 7th webinar event for 2024.

We are obviously preparing, warming up for November 28th and 29th

when our 35th Congress of Gastrointestinal Surgery will take place.

We hope to bring some novelties.

Every year we bring something new.

And in these webinars, we take the best live videos made by colleagues that have satisfied us,

that we have seen were most followed.

And this time it's Professor Massimo Viola's turn,

who will comment on his from tricase let's say his subtotal gastrectomy with d2 lymphadenectomy

it's a procedure i've seen several times very beautiful schematic and masterfully done with us

we also have professor angela pazala with whom we share a deep friendship for several years

we won't say how many years because otherwise we'll reveal my age not the professors then

Then there's Roberto San Pietro, and as you can see, we try to keep all of Italy in check and

try to use the best resources we have in the field. Massimo, I give you the floor. As usual,

you're already accustomed. You did one last year on the use of electrosurgery,

so I give you the floor and start comfortably. Your two commentators, if they see questions,

will interrupt you to tell you what topics are being requested from you. Massimo.

So, good evening everyone. A warm thank you for the esteem and affection that Professor

Palazzini has always shown me. Greetings and a hug to the two colleagues with whom more than

just one is shared. Technical and professional participation. Also a connection, if I may say

so too. True friendship. And above all, a greeting to those who have decided to spin this afternoon.

Let's say this late afternoon with us to have a chat about laparoscopic gastrectomy

on the total.

It is a procedure that, as mentioned before, has already been somewhat subject of a very

recent live event.

And why do we want to fine-tune it in this webinar?

It's pure, just as you see it live in one of Professor Palazzini's meetings.

So, if you want, we can already start, so we light up a little introduction on what

that is.

However, well, each case is unique. In the case of the patient with an adenocarcinoma

of the gastric antrum, as always, beyond the gastroscopy with biopsy, we perform an

endoscopic ultrasound. Do you see a staging CT scan? This is a small detail to show an anomaly

we will encounter during the surgery. It's a gastric, a right hepatic artery that originates

from the superior mesenteric artery. These are the two somewhat vascular characteristics that

have marked this surgery. Vascular reconstruction is interventions, let's say, of gastrectomy,

but a bit in everything. The supermesicolic for us is always fundamental to have a topography

of the mental anatomy that we expect. Other small preparatory details were precisely an

exploratory procedure that we perform on all patients affected by gastric neoplasia to

exclude. There may be carcinosis or positive washing that would change things a bit for us.

So the patient, from her staging, is a patient who has a clinical type T2 gastric adenocarcinoma,

in the absence of suspected lymphadenopathy or distant metastasis. This is the nutritional

status we evaluate in all patients, whether we treat them directly, which are very few,

at least as far as gastric tumors are concerned, because they almost all go to inadequate,

both in patients who are subjected to neoadjuvant chemotherapy before the surgery.

The steps we will see are, as you can see, the opening of the dissection with the omentum,

starting from the left. With the left omental vessels, we proceed with the lymphadenectomy

on the splenic artery, and we move to the right gastroepiploic vessels. With the subsequent

subsequent sectioning of the vessels of the right gastric and the duodenum, and then we

move to the proper hepatic pedicle.

The hepatic pedicle is more or less dissected according to, let's say, the state of advancement

of the disease, and then we complete everything with the tripod.

The esophageal lymph nodes on the right side and the section now a small detail.

We have done in our experience one initial, let's say, experience with endocyanin green

mapping to verify if our dissection. It somewhat corresponded to what naturally happened with

endocyanine green when it arrived. This is a fairly old video. By now it will be 5 years.

6 years since its date. Initially, they did, precisely, the administration of endocyanine,

as you saw in the previous slide, with 4 cardinal points and then based on that.

They followed our routine laparoscopic infectomy, simultaneously evaluating what

were essentially the dissection fields before and after the dissection, to verify if our

oncological approach also corresponded to what we saw and that roughly.

There are no particular advantages regarding what is the lymph node mapping, because it

roughly corresponded to the lymphadenectomy that we were used to performing.

In fact, in some ways, it could be somewhat counterproductive because after a while the

lymphatic damage could also reach the retropancreatic lymph nodes, thus causing some

issues. This is pushing a bit towards an overtreatment that, in reality, is not necessary

in D2 infectomy. As you can see, this is a case that also has those vascular characteristics we

will talk about today and that we saw on the CT scan. This patient, as you have seen, had a right

hepatic artery that originated from the mesenteric and this is somewhat the whole thing. Let's say

the surgical field was verified both before and after dissection with endocyanin. This particular

detail. You see the right biliary ducts of the six. The ligament. You see my bile duct pulled

to the left. This is the course of the superior mesenteric that detaches as you see the right

hepatic which is carried posteriorly to the portal as we saw in the CT scan of the case we will

present today, of the patient whose video we will see, and the check. Let's say that we did with

endosynine green both in this and in a series of cases that we carried out during the first

experience, showed us that essentially we could consider, even in advanced cases, sufficient

lymphadenectomy, the one we conducted. Let's look at the case being discussed. We start,

art, as seen in the initial small frames, with the opening of the gastrocolic, a brief mention

of what they are. Normally, I position myself between the legs. The patient is in a supine

position with their arms open, and the drugs are placed, let's say, in a diamond shape but with

the trochrotico slightly shifted, to the left, that is, towards the left side. I do not like

like to place the optical trocar in the umbilical area as many do for gastrectomy because I find

much more comfortable in the vision, especially of the lymphadenectomy during

upper margin of the pancreas. That's where we are. On the left side, we mentioned that we prefer to

start the dissection from left to right. We begin by identifying the splenic artery and then conduct

an infectomy that starts right here on the vessels on the distal splenic. As you can see,

a dissection is a type of dissection that

we prefer

after having tried several

the one that is done with monopolar current

and with radio frequency

that instrument that you have seen

and that you will see again

which is precisely an instrument

we say very effective for

for the dissection

and we also believe

for the reduction of lymphostasis with

also an attention

in the lateral thermal stress

that seems to be a bit more

let's say sure at least I repeat in our experience the distraction as you see is

a distraction that tends to be an in-block dissection that is not we

perform a lymphadenectomy on the various stations that are then sent separately

if we can manage the fatty tissue with the various lymph nodes is somehow

detached and left in a block with the piece that once extracted separated to

send the lower stations to the pathologist in order to have a more accurate staging

including lymph node staging also of the various stations isolated here you see the part of the

illus lenico we continue from left to right always with the landmark which is precisely the profile

from the upper margin of the pancreas and the splenic artery which we gradually follow leading

Leading us to its origin.

Of his own.

His emergency?

On the tripod, we continue to the right.

Do you see the monopolar current?

Does it somehow?

The function of almost drawing our way.

The lines that lead us to lymphadenectomy.

It's precisely that, let's say, removal of lymphatics and lymph nodes together.

I wouldn't want to bore you, but still.

This is, as you see.

A kind of continues careful passage with the dissection, careful, especially to avoid thermal

stress that can be performed on the vessels. As I was saying, it has been quite long from the left,

essentially producing a kind of sheet that contains all the lymphovascular structures.

This allows us the left, for example, in addition to having a continuous view of the splenic and

pancreatic structures, the splenic vessels, and the pancreas. You see there in the background

on the right? You can glimpse it. There's the hook. It's also targeting the left adrenal gland.

So, all this sheet with the fatty cellular tissue is gradually being removed.

In a single…

In a single true block, right? Now there's this little detail. That is the attraction from Juan.

Of the month.

and those in which, excessive traction, thermal stress could lead to some not exactly pleasant

postoperative surprises. We have essentially reached the halfway point of the dissection

along the upper edge of the pancreas. We are almost there, precisely, at the origin of the

splenic artery. As you have seen, let's say in the initial moments when I showed the main steps,

steps. The dissection at this point moves onto the right gastroepiploix, and therefore the

station is actually in this case. We went a bit further on this part of the dissection of the

supramesicolic, sorry, of the, of the splendid, and therefore, of the vessels, here. This is what

I was telling you. This is the lower edge of the pancreas, right at the proper hepatic,

which is a phase that as we have seen in the initial phases we only do after having sectioned

the duodenum and brought it onto the stomach in this case we conducted it for a vision because

the vision allowed it we conducted it before resecting the but it is not our habit to perform

it in this phase only when actually the characteristics of the patient and the vision

and allow it, to such an extent to follow a bit this part, to perform this part safely.

You see, this is always the sheet we were talking about and is dissected, almost in block with the

lymphatics. As you see, this instrument allows us, with the help of the hook that gradually outlines

the parts, removed, it then allows us to also perform those sutures of the tissues, even near

the vessels, without the fear, let's say, of having particular thermal stress as I mentioned

before. Massimo. Do you see there? Massimo. I hear you. I have a question. Yes. I just wanted

to say this, that this is the famous Bucciarelli triangle starting to come into view, because this

is exactly the point where the common hepatic artery, as you can see, on the left the gastroepiploic

and right under that triangle. Can we identify the portal? No, no, but I won't interrupt you much.

But if I quickly tell you, regardless along the same vessel, the same dissection both the hook

and the radio frequency instrument, which to me here next to me might not seem, but there are

quite a few people, young ones. They ask me what's the difference, why use one over the other for the

same, let's say for the same section of the vessel, let's say lymphadenectomy. So if I used

one ultrasound instrument, it would also be almost superfluous to use the hook, and one

could do, or one advanced bipolar in case I use, as in this case, an instrument that

is a radio frequency. Drawing the opening of the peritoneum with the hook and therefore

with monopolar current is much more precise, as if I were drawing, the path then to follow,

and thus exploiting. Let's say of the detachment of the pneumo that with small detachments

allows to identify the structures, the planes more, more easily. It allows me then to complete

with the synthesis of any lymphatic vessels with instead with the radiofrequency what are now the

large lymphatic structures that I go to, to select in such a way as to reduce. No, that was what I

wanted to tell you, that to the young ones, your use of the hook so beautiful, practical, etc.

It must be said that you use it by pulling the hook, because that disc of the hook is electric

current so it's very delicate it doesn't have a protected back so just that concept you were

talking about of electric current transmission of thermal damage we must be careful and we really

notice your use pulling we also notice this traction you i believe have five trocars here

so two that pull you up and then your two instruments and the optics so you have five

trocars for trocars but there aren't two that translate over just one but just one perfect

Perfect. Thank you. Sorry.

And the hydration is so good it seems like there are.

Did you see how beautiful?

Massimo, I wanted to ask you a question.

The approach on the splenic artery from left to right,

then going towards the tripod is definitely not usual.

Not everyone does it.

I was wondering, watching this video,

if with patients with significant BMI you manage?

Anyway, to follow this approach or…

You have to modify it.

it. My tendency, for example, is that I find it much, much easier for me. And definitely

maybe technically simpler than going as you start from the splenic artery, let's say

mid-distal. It's like always like all of us go to the upper margin of the pancreas

at the level of the common hepatic from there, you almost always have the distinction that

little sheet between the lymph node the group of lymph nodes of the art you detach it maybe

with the hook that as you say creates that vaporization of the tissues. Then from there

you move to the tripod and it's much more intuitive to find the splenic and then do the

lymphadenectomy. So I wanted to ask you if in patients with high BMI you find this approach

always feasible or you have different needs. Let's say that as it has happened to all of us,

as is, it's quite intuitive. The splenic does not unfortunately have a constant course and a linear

direction. Sometimes there are also very convoluted, very risky splenics to dissect.

So, I realized that identifying the splenic at the simplest, most visible point sometimes then

creates the possibility of sense generally below when talking about patients with high BMI.

Naturally, the approach can also change because it can also become very difficult even to guess

what is the upper edge of the pancreas which is covered by the fat ingressor that almost almost

almost, becomes one with the lower fat infiltration. In that case, naturally there are the classic

landmarks you were talking about, which are much simpler to follow. Perfect, perfect, perfect.

Let's move on. Here we are still as if we were looking at the celiac tripod from the left.

Do you see the left diaphragmatic pillar? We know that the tripod comes out from two pillars.

In fact, there is the arcuate ligament in some patients that can be identified at this point.

The dissection continues by removing the lower fatty tissue of this area.

As Professor Pazala rightly said, as you can see, the hook is almost like when working with

the dissection and isolation during a cholecystectomy. We are always very careful to

direct the tip of the hook towards structures that can be. Meanwhile, here you see the left

gastric artery emerging from the tripod the gastric vein which in this case is

not a true left gastric vein but is a right gastric vein because if you see it

passes behind the mesenteric behind the common hepatic and it heads exactly to

the porta hepatis that is it comes right from the porta hepatis here this passage

makes it makes it easier to understand this is the origin of the vein gastric

which for me is a right gastric vein, which normally is much smaller because naturally

the left gastric vein is the one that in this case is not present and is isolated and sectioned at

this level, the clamp is pulling the lymphatic fatty tissue that covers the proper hepatic.

So, we are indeed inside that famous triangle we were talking about earlier.

The portohepatous is under the lower edge of the pancreas and the base of the triangle and

and the two sides are indeed the proper hepatic, and the gastroduodenal, which is at this moment

to the left of our clamp. The fatty tissue around the pancreas continues to be removed, as you can

see, in a block, the dissection, of the lymphatic tissue around the left gastric artery. In this

case, it is extended. Why? In this case, it is extended because, as we had mentioned during the

presentation, we had seen the initial CT scan. The patient has a left hepatic artery which is

not particularly dominant but which we have tried to preserve, which comes from the left gastric

artery, so we do not isolate it and at this point, it might also be much more convenient for many

reasons, tempting its dissection to maintain, hoping to subsequently maintain, let's say the

left hepatic branch. So, we separate the fatty tissue that covers it on the right and left,

so that we can then remove it. Circumferentially

This, as you can see, is still a phase that, with the stomach positioned would have given

a bit more ease. However, we continued to conduct it mostly because. Because at this moment,

the vision allows to identify the origin of the left gastric artery and essentially, we could

decide if during the preparation we had damaged it. To close it directly and not go ahead.

Let's say with this fine dissection.

Mossimo here sends another strong message, that the patient must be well studied beforehand.

6-7

All this because I say he had told the young people the patients must be studied beforehand,

you know well where the gastric the hepatic starts, you have studied it well,

so you were able to treat the patient well. A strong message this that we must give, right?

At this point, I can't see anymore. Here at this point, roughly the origin we have more or less.

Isolated for a stretch. Let's say that's satisfied with the fact that. There, you see at the top.

The right diaphragmatic pillar. This time the muscle fibers. That can be guessed behind.

This essentially makes us understand that. We have somewhat arrived. Here. This is the vena cava.

lava, the caudate lobe, and this is the fat, precisely the inflamed fat that is adhered

the fatty tissue essentially takes us up to the right gastroepiploic vessels, as you can

see below. It will always be horizontal. Land, which is the profile of the pancreas, and

and the upward traction of the stomach? Yes, as we will see, it allows us to

see a bit of the origin of our vessels that we will go to search for below due to gravity

because the patient in anti-Trendelenburg brings down the transverse mesocolon,

and this allows us to even reach the superior mesenteric artery,

which as you can see at that point passes under the pancreatic isthmus.

So, this will be the middle colic and the dissection of the cellular tissue.

The fat above allows us to be quite confident in completely removing the fatty cellular tissue

that. It is indeed part of the lymph nodes. Eyes. The right library. Mossimo. Perhaps we

should remind those who are less. Who are less. Who are less accustomed to this type of surgery

or anyway. Residence. This is an area to be treated with great respect due to the fragility

of the trunk of the nerve. Can it really cause discomfort? Important, exactly, since we are

sending messages. Take messages, maybe occasionally. It's worth remembering that dancing around these

structures requires caution, and even when you use the hook, as you often do, as it was said,

it's something that is gained with a lot of. A lot of practice and a lot of. A lot of experience.

experience. Look, I was reflecting on this some time ago, having those famous memories in which

in open surgery, both in the preparation during the duodenocephaly and during the gastrectomy

and even during those, right colectomies for advanced disease, exposing the trunk of Henle,

it was extremely common for it to start bleeding. What I was reflecting on was precisely this,

at a gentle upward traction of the stomach. It's the effect of the pneumo, if we say guided by the

opening of the correct spaces, minimizes the trauma as much as possible. It's my idea. It's

an impression. It minimizes the trauma as much as possible and naturally. The vision that now

with new technologies we have, with the island with 4KO, with also the three-dimensional division

vision that can be either laparoscopic or robotic. Allows to really stay in those areas with a

relative. Let's say. I say simplicity. In the sense that I see better. So by seeing better,

probably even the tractions are gentler. It's easier to dominate what are, as you said,

very complex surgical sites. Yes. Also sometimes really waiting a moment to be helped by the

pneumoperitoneum. As you said, here as in many other districts. Really gives you. Helps you.

So much so. So indeed. These are areas where haste often does not pay. That's it.

I agree. So the approach is slow, but fast. Continue the dissection as you see these larger

caliber lymphatic structures are synthesized with. Radiofrequency you see on the left this

colic arterial branch, which continues to be, let's say, stripped of this, group of lymph nodes

and lymphatic tissue, in such a way as to essentially reach that point where the leaflet

of the transverse mesocolon is located. It merges with precisely that, from the group of the right

gastric vessels. At this point, we also identify the location where the left colic flexure.

It virtually attaches to the duodenum and, once that is detached, the clipping, ligation,

and sectioning of the right gastric vessels are performed. We are ready, at least on one side,

lower to be able to conduct our section of the duo which then, as we will see, will also be

completed with the section of the right gastric vessels and the epiploics. As you can see,

it is inferred how we are approaching the pancreas. Another thing that, in addition to

the fragility of the L-trunk, in my opinion, is fundamental to be able to avoid, that is,

it's the discontinuation of its capsule or its trauma. Because in the postoperative period,

there can always be pancreatic micro fistulas due to performing quite extreme surgery on these

stations, which could then expose to some postoperative discomfort. Indeed, it's also

difficult. That is, its origin sometimes might seem difficult to interpret. In reality, I believe

that. The onset of pseudoaneurysms or delayed bleedings, which can occur precisely from the

fourth to the fifth day onwards in these patients, it can indeed be caused by, in addition to

microtraumas or thermal stress that can influence the onset not to forget this as well what could

be the pancreatic micro fistulas precisely due to a lymphadenectomy that is carried too close to the

capsule as you can see we have already dissected the right gastric vein with the aid of using

radio frequency we now isolate and will section this time between clips the right gastroepiploic

artery that you see, which is indeed the continuation of the gastroduodenal artery

that we initially identified. This essentially gives us the limit to where to conduct the

ligation and sectioning. This is another one of those places where isolation can cause a bit of

whining, as you've seen with some basal plants that usually interfere and cause trouble.

Naturally, the use of these clips is absolutely not. Titanium clips are also perfectly acceptable.

acceptable. Let's say, for us, it has become somewhat of a routine use. A daily routine,

yet without specifics. Contraindications to the use of others? From other clients? Yes.

It must be said that these always give a great sense of security.

Yes, I expect. The metal ones from those places.

In short. There is definitely evolution. Then the costs are different so one evaluates.

But objectively there are points, where you don't mind having something that holds more securely.

That is, at this point, nothing completed a bit, isolation and cross-sectioning to the right.

As you can see, there is the duodenum that we are preparing, from its lower side.

Subsequently, after making the incision, this fat is moved aside, to the left.

At this point, before the duodenal session, we also complete, as you can see, the ligation,

the sectioning of, ligation of the right gastric artery. The stomach is then brought downwards.

Here we had already isolated and identified the common hepatic artery. It then becomes very

simple, let's say. To understand what the next steps are, this is the fatty tissue that covers

the left gastric area which, as we mentioned, we intended to preserve. To precisely maintain

that left hepatic area which essentially served the second segment. This phase is completed.

Naturally, in these, there are various small branches going towards the lesser curvature

that need to be selected, some a bit thicker, possibly sectioned between clips. So, as we

We were saying the fatty tissue, as you can see, previously mentioned, supported, it is

being pulled, and isolated.

In this case, due to space issues, we put a small metal clip and naturally continue

here as well, with the separation, naturally, at this level of the fatty cellular tissue

that will then be pulled towards the left in the second phase of the lymphadenectomy.

We identify the left hepatic artery.

It continues to ascend. Why? Another small detail, if you might be interested, is

emphasized by the traction of the liver of the left hepatic lobe upwards. This does nothing but

produce a traction of the left hepatic artery, which is therefore always under vision. As you

can see, it heads towards the liver. Here we coagulate the right gastric artery that we had

clipped and we move along the upper edge of the gastro renal until we reach the duodenum

at the corresponding precisely upper edge which we will isolate before the sectioning of the

duodenum itself these are the last pyloric branches to have a properly prepared viscous

and at this point we section small adjustments before dissecting can you show us an overview

view of everything, a panoramic view? But Dino isn't there, how silly of me, sorry.

No, no, but anyway, it will be seen later. I was convinced I was at the Palazzini and

commenting live. You made this video so beautiful that I was almost convinced I was live with you.

But I tried not to cut almost anything. So I removed the cleaning and the optics.

That's it. Explain that the loaded stapler and all here are the young ones, come on.

And above all, I removed the audio because the audio from the Palazzini is always an audio.

A bit peculiar.

Mossimo, do you do the control of the duodenal stump with endosynine green?

Right?

No.

No.

Why?

I must say that we are in an ecclesiastical hospital, and we are full of Madonnas.

So we have never had, I believe because they are protectors of the duodenum,

never had duodenal problems and gastrectomies.

so I never felt the need. Then usually using the blue load, which is a load that is quite

hemostatic, but let's say not as vascular. I always see the edge of the pancreas in the

middle of the clips, as you saw earlier from that minimal moan that somehow

does it reassure you? Almost makes me think that it's a bit superfluous to also do a test with,

but I repeat, not me. Then I am convinced that the vast majority of late duodenal openings are due

to. A discharge, let's say. A difficulty of. Canalization of the foot dance loop if one does

the ruin Y or of A. I mean, I am convinced that it's a matter of pressure. A pressure issue.

So by doing anastomosis always to the foot dance, or with 160, or doing the B2 that you will see in

this surgery because, depending on the age and the state of advanced disease, as you wish,

we could discuss later. Broadly speaking, I lean more towards AD2 or a ruin Y. These are always

very wide anastomosis, which have never caused any discharge difficulties, so I don't know why,

but I am convinced that. The success is probably due to that. However, from memory, and again,

it's not completely lost if I have to say no. Among the most feared complications,

Complications? After a gastrectomy, even with extended lymphadenectomy, what could it be?

This or any way those that we normally conduct, which are more or less the same.

The complications? Among the most feared complications, I don't include the duodenal

one. Listen, I haven't seen. I didn't notice that blue one was one with three lines of suturing.

Yes, yes. And there, perhaps those too. Actually,

if you remember, I mean duodenal fistulas, if there were any.

with the and there were many more seen there were i mean i believe that actually the introduction

of the trist yes i agree before two lines of suturing someone would sink it sank for a very

long time anyway you had the problems instead i must say that indeed almost regardless of the

of the brand for sure the tri stapler brought an advantage as well also in terms of sealing

Whether it's a vascular problem, or a problem as you say of pressure anyway these.

These three rows hold very, very, very well.

This I share too, this in all anastomosis.

Not only for the duodenal stump, but in all the three rows now facilitate, help us, eh, will there be data?

As you see this is the sheet that continues to be pulled with a slight traction towards the patient's left,

and does nothing, but give us the possibility to also remove the 12 lymph nodes that are slightly rolled.

let's say outwards by this traction at this point in this patient we are particularly

careful because we have it was verified that from the preoperative CT scan he has a