Prof. Huang Changming Totally laparoscopic radical total gastrectomy

Morning. Do you hear me?

Yeah, Professor Drugo. Nice to see you again.

Nice to see you again, Professor Wang.

The opportunity is great because, as you probably know,

tomorrow in Rome, in my hospital, I have the honor and pleasure to host

your boss, Professor Gong, who will present his great experience

on complete mesogastric excision from my university online

and today we are we are glad and anxious to to see the demonstration that you are

going to make here today so so so nice to see you again possibly in April I

will be in Wuhan and we will meet again thank you and so we use your case yeah I

I will introduce my case in our hospital.

Can you see the PowerPoint?

Clearly.

Yeah.

And thank you, Professor Duyguo, Professor Giacobbo.

And today we will have a live surgery

from China for the Medical University Hospital to Italy.

This patient is a male, 55 years old.

Yeah, his BMI is 21, and he has a chief complaint of recurrence of abdominal pain for seven years,

a great city for one month, and he has no special medical history.

And the physical examination was normal, not a positive symptom.

symptom and tumor market market CA was 2.5 a 2.4 and CA 125 is 7.9 and

you have the CT scan I will show you in later and endoscopy and it

it shows a lesson of a block makes the 1.5 centimeter point uh eight point uh 0.8 centimeters

in the last curvature and we can see that this is uh city scans is in the last curvature and

The CT stage was about stage T2, and endoscopy. Endoscopy showed in the last coverage of the lesson.

And so today, our diagnosis is gastric cancer. The pathological show is gastric adenocarcinoma.

And today, Professor Fang will want to perform a totally laparoscopic radical total gastrectomy.

And that is our case report.

We may, the operation, we can have the live surgery.

Okay.

Professor Fang, and all the experts from all over the country,

So you are injecting ICG?

Could you please explain how much concentration of ICG and where you are placing it?

Okay, I will introduce the stop psilocybe inject ICG method in our center.

center. As you can see, we have six points totally in the stomach. The great curvature

was three points and the last curvature was three points. In the great curvature, the

lowest point is the right gastrointestinal artery, the first branch to the stomach was

near by this point. And the last curvature point is in the right gastrointestinal artery,

the first bench to the stomach wall for this point. And the second wall in the last curvature

is you can just the professor has an injector in the kernel in a stomach and

ankle of the stomach and the but the third pointer is between the first and

second venture of the left gastric artery yeah this is it's the three

points in the last curving. This is interesting because you are not injecting first the peritumoral

site through endoscopy, but you are just injecting the four cardinal points in the stomach in order

to trace just all those nodes that in your strategy of operation are considered to be inside the D2

to fill is that right yes yes we the end of our this method inject the icg is to shield the d2

d2 lymph nodes during the operation and not uh not inject nearby the uh nearby the um

tumour, nearby tumour. So the great curvature will have one point in the founder, in the great curvature, founder of the great curvature.

Maybe it was showed the number 10 lymph nodes.

At each point, we were 1.5 milliliter of LHG.

I also saw that Mr. Huang has written a video saying that it is better to recommend pre-injection injection.

Are you now using regular intravenous injection or how to choose the two injection methods?

Currently, we are using regular intravenous injection because our research shows that

the effect of intravenous injection and pre-injection injection on lymph nodes is quite similar.

In our research, we can see that the injection in the tree is more simple and the patient's endurance is better, so don't do another gastroenteritis.

Is the omentectomy always a part of your radical operation, or do you sometimes discard the removal of omentum?

Oh, yeah. Usually for advanced gastric cancer, we will remove the great omentum.

Now, maybe tumor as a T-stage was not invasion of serosalt, we will prevent the great omentum.

Today is life shield, so we will have to remove the great omentum.

It's because there have been studies that have been demonstrating the not total usefulness of a mentectomy, especially dedicated to those who in the West perform laparoscopic gastrectomy, where patients have a major BMI.

So a momentum in a small field during a laparoscopic operation can be, you know, very annoying.

Jianxian?

Yeah.

Yeah.

Yeah.

Can you please mention again the patient's clinical stage and also the position of the

primary lesion?

Yeah.

From the CT scans and endoscopic, today these patients were clinical stage T2, N0 to N1

from the CT scan.

And so it's a live show. We will have the total gastric atomy with the D2 lymph node lymphoectomy.

And I think Professor Wang will have the number 10 lymph node for training how to perform the number 10 lymph node dissection.

And the precision of the trammelation was located in the last curvature.

Okay.

Usually, if the tumor is located in the greater curvature, the number 10 lymph node is important

to dissect it.

Because today's live surgery, we can show how to, especially for a young surgeon, how

how to dissect the number 10 lymph nodes

by Professor Huang and Professor Zheng.

I think it's meaningful for all the surgeons.

Okay.

Professor Ugo, do you remove the great omentum

for the Italy patients?

How do you choose the patients

who need to remove the great almond head?

Well, we always discuss this because the aim of the operation,

when the tumor is still contained inside the original membranes,

should reach just the lymph nodes that are part of the tears that are called D2.

Now, it has been demonstrated that outside of the two centimeters

in the distal part of the greater curvature vessel,

there are no lymph nodes.

Omentum contains just those that are called milky spots.

So removal of the omentum is just a part of the operation

in order to prevent carcinosis.

But if there is seeding and carcinosis,

you are in effect operating a stage 4 tumor.

So for a really resectable and curable operation,

omentectomy should not be compulsory.

Sometimes in very advanced cases, in order to perform a good laparoscopic operation,

we interrupt the gastrocolic ligament, we complete the operation,

and then remove the omentum at the end of the operation.

A resident can do it after the most difficult part has been completed.

So sometimes we don't do it, sometimes we do it in two times.

Okay, thank you.

Another interesting question that somebody is asking me right now, looking at you,

is why don't you start the operation with a sort of liver suspension are you don't are you

applying a liver suspension afterwards or you don't do it at all

Yes, this is a good question.

I didn't notice that he was asking...

An Italian expert asked why there is no liver suspension.

Is it because you want to lose some liver or you don't want to lose liver?

Liver suspension.

Yes.

Usually, for the lymph node dissection, we will not the left liver.

因为你们做权位,常规不掉肝吗?

在淋巴结其实有常规不掉肝,

但是我们在消化道重建的时候会掉肝。

哦,Dr. Professor DiYugo,

Dr. Jian Xian mentioned that for performing the liver delectomy,

Professor Huang usually not suspended the liver,

but will suspend it afterwards.

before the GI reconstruction.

Right.

Yes.

If you get a stomachache,

you will get a surgery.

Is it your camera?

I told him not to use the camera.

Did you get the camera for him?

Yes.

Professor James,

do you usually have a selective cut-off massage

or does everyone have a cut-off massage?

I know this patient has a cut-off massage.

Yes.

Yes, it's usually a selective surgery.

If there is no incision, you can do a resuscitation surgery to preserve the large intestine.

If there is an incision, we usually suggest a large intestine resuscitation.

Is it T3 or T4?

Yes, it's usually T3 or T4.

We will do a large intestine resuscitation.

Okay.

This is the one.

Let's soak it.

is reaching and preparing and disposing lymph node station number six i understand from these

pictures yes we were first we were dissected number six then number 11 p number seven and

number nine number eight eight and number 12 number five and number 12 a and then we were

dissected the number uh 4 sb and number 10 and then number number two from the right to the left

are you following the concept of membrane anatomy in order to identify a complete

around the origin of the vessels.

Can you briefly explain about this idea?

The hand-led trunk is perfectly exposed and you are clipping the origin of the right gastroepiploic vein.

We see very clearly the nodes that are painted in green belonging to station number 6 going up together with the bursa containing all the nodes.

Yes, exactly.

Exactly. And also, the fluorescent imaging can classify the membranes of the colon,

the mesocolon, with the gastric, so-called gastric mesoprane.

Exactly. See that you follow the green and the right plane goes up together with the green

and the rest is the surface of the mesocollum.

Yes, it is.

This is a

disengaged and mobilized.

The station 6 is going up.

All the rest is not belonging to our pre-operative plan of removing D2 lymph nodes.

Yes, we can dissect lymph nodes from the surface of the vent and artery and make them all in the upper side.

In order to identify the origin of the gastroepipelaric artery just below the meson origin, just there, this is a pre-pyloric vessel.

holding by the professor from the assistant of professor one professor is

holding by the president and his assistant for professor one usually

teach to our resident is that especially around the hand the trunk the anatomy

there is no normal anatomy there is a huge possibility of vascular variations

in terms of you know sub pyloric vessels and alternative vessels that goes in

in this area okay so we can see the number six lymph nodes was have a great light we have

finished the dissections uh for the number six lymph nodes and there was no great light in a

operation field so we were second we will have super pancreatic lymph nodes

dissections yeah it's a ICG modeled and normal lines not model it's great this

is your next step you don't need any liver suspension because you are

suspending the stomach itself and you're going directly to the supra pancreatic

area yes yes we we have a smaller or maintenance and the word of the stomach to the left liver

Pansions.

Yes, we can see the lymph nodes in the supra pancreatic area.

And then they have the red, green lines.

In the supra pancreatic area, as you can see, usually we will first dissect the number 11

pit and from the pancreas, the body of pancreatic, in the upside we will shoot the proximal of

of the spring arteries and we were dissected a number 11 peter around the spring arteries

until the um left gastric artery and left gastric vein usually we called this as a left approach

from the left to to the right side left side to the right side

see it is extremely convincing and clear yeah today today we use the stars the

now you follow the Angels hair keeping the notes at this year adherent to this

splenic artery yes it's here uh actually i think it probably uh this here is very difficult point

because of pancreatic and as a spleen artery sometimes you have two pressures uh pancreatic

and either sometimes you uh detect this part uh lymph node uh sometimes you can't see that

especially most of Chinese surgeons they would like to stand to the left side of

the patient so here is easy to miss the lymph nodes so this part probably very

important part in the dissection lymph node so ICG is very helpful to

ECG is helpful and protecting because, as you mentioned, there is a paper that has been published identifying in this step with compression of the pancreas the possible cause of post-operative fluid collection because the pancreas is a very, very delicate parenchyma.

From the proximity of the spring artery to the right side, we can see it's easier

to reveal the root of the left gastric artery, and we will dissect the number 10 and number

first when performing the super pancreatic area so you go directly to the vein and the left gastric

artery yes we it's routine to a method we perform the lymph nodes in a super pancreatic area

Most people in the West perform duodenal transection, fraction of the stomach cap, and then identify

the suprapancreatic.

Yeah, in some centers, they were from the right side to the left side, first have transected

the duodenal.

So Professor, actually for most of Chinese surgeons, they would like to stand on the

left side of a patient is it's uh different to uh japanese or korea surgeon they would like to stand

to the right side on the right side of the surgeon of the patient so um for chinese surgeon

they would like to use this approach especially from the spleen artery this area it's most it's

easier to do this the section procedure yeah I will agree with the professor

finding yeah but can could you please show again to us the position of the

surgeon around the table can you switch the camera to to observe how the the

team is positioned around the table and conscious any Barney go watching the

and can you see the in the screen right side of the screen screen and professor was

sitting at the patient's left side and the first assistant was sitting in the right side

patient of the patient's right side and the camera was holding in the middle now we see it

Yes, so usually we work from the left side to the right side to have lymph nodes dissection.

There are enlarged lymph nodes in this area. It's number 88 lymph nodes.

And when dissecting the number 10 stations of lymph nodes,

do you change the position around the table?

Oh, yeah, yeah. During the number 10 lymph node dissection, the surgeon will stand in the middle of the patient's two legs, and the camera assistant will stand behind the first assistant, both in the right side of the patient.

right ask again if this hand the left hand that we observe is the hand of the surgeon or is it

it is the hand of the first assistant the left hand holding the aspirator it's holding by the

first assistant you mean this section doing a very important part of the job this traction

and counter traction are essentially dependent on this left hand and it's very good

it is holding holding by the first the assistance right hand yeah it seems like

one person to perform the operations do you see at the perfect team they're

working together in a very very mmm you know organized way and this is very

difficult I mean you must be you know a very important team that has been

trained perfectly yeah yes and it's uh it's like the same person do the user both both hands but

actually they are different so it's we call that teamwork so it's a professor professor's model

and we were learning we were learning as a professor then the assistant then when we have

to perform the operation our assistant was also learning like this model to have the operation

so uh it's very effective especially some of the bmi is higher and sometimes it's bleeding or you

know the tissue is not good so a system can use a section to do a lot of work to make the operation

area is very clear so it's very helpful and more effective yeah yes so now you are clipping the

right gastric vessels right yes yes yes well this is very difficult because with fatty patient

you know the right identification preserving with no damage the hepatic artery sometimes is tricky

so we have to perform the approach the right gastric artery from this other side from the

side of the hepatic column yes not pro yes it's very important it's a different to the fight

tissue actually the fight tissue is big problem for the surgeon i think every surgeon you know

they think this is uh the fight tissue more fat tissue will be difficult a different difficult so

So I suggest Professor Huang and Professor Zheng, next time you choose, you know, a lot

more tissue patients to share this.

Invite them to Europe is not going to be very difficult to find it.

Yes right, yes right.

yeah but anyway I remember the in 2019 the way went to the attorney

oh hey yeah yakuza Center we have two operations in the high BMI species

important they make our field more clearly the smoker will be sectioned

sector

somebody says that these are the only nodes that should be clipped because the

lymph that drains out of the liver sometimes is so much that you can have

fluid accumulation.

So, usually we don't use the clamps in this area, sometimes, they prefer to use a clamp

in the superior pancreatic left area.

Let's see if we can move it.

Professor Huang, do you plan to cut off the 12-inch length first?

The 12-inch length is going to be cut off.

After we're done, we'll put it in the door.

Okay.

Just now, the Italian professor was also concerned.

He said that they are relatively fat.

They might consider cutting off the 12-inch length first before doing it.

The reason why we cut it off first is because

the interlocking is interrupted.

Sometimes we feel more sleepy when we're young.

It may work better if you put it in a closed vein after the rupture.

Yes, choose the right time to do it.

Give me that.

Professor Ergou, could you please turn on the microphone?

We cannot hear you because you turned off the microphone.

Yes, please turn on that.

Do you hear me?

Yes, we can.

yes we can no it's turn off yes yes I are you using a white cartridge okay

right now it's it's okay yes please I mean we were noticing that in order to

transect the duodenum you used a white color cartridge for the stapler yes we

use the white the white for us usually is done for vessels and they discourage us to use the

white for the duodenum too too much crunching yes actually uh it's not uh every surgeon choose the

was a white uh linear stipper actually uh i think we we didn't uh actually i use i prefer to use the

blue blue one i think probably most of our chinese surgeons they would like to use the blue one

but uh for for some patients you know uh some bmi is a very uh lower and the

urinal tissue is very thin so they would like to use a white one actually i think that's um

they have a this experience it's very safe for them we know that's for the vessels

but actually used for the adenine, it's very effective, it's very useful, it's very good,

no bleeding.

Professor, do you think the white nail is used on the blood vessels, or is it a little

too much?

The small intestines are all used on the white nails.

Yes, he just said that the white nails are used on the blood vessels, can you use the

white nails on the 12 intestines?

Maybe it's because the blood vessels are not oxidized well enough.

It will be easier and more efficient.

I totally agree with you.

Professor Dian Dian, I have a question for you.

We will ask Professor Dian again later.

So you are starting to see the lateral border of the portal vein right there.

ago could you hear me okay yes very well okay this is dr xin from peak university cancer hospital

and dr lin and i will just talk about the proximal gastrectomy proximal gastrectomy

you know in china in east asia so china korea korea and japan there has a trend that the

incidence that the incidence of uh upper uh gastric cancer and the tumor located in the

each junction is more and more popular.

So there has a trend that the proximal gastrectomy

is more and more popular in China.

So I want to know what is your opinion,

what is your choice?

Well, you are very right.

And in the West, it's even more evident.

And somebody says that according to the incidence

and frequency of solid tumors,

even if the numbers are not that high high located EEG junction tumors are

possibly the most fast-growing solid tumor and this is related to obesity and

change of lifestyles anyways our rate of early detection still remains very low

so okay total gastrectomy is the preferred choice operation in in many

many cases proximal gastrectomies now have been learned by european surgeon from the eastern

colleagues and we started to perform this proximal gastrectomy for gist tumors or uh in a very

special early stage junctional cancers there are different styles of reconstruction in order to

avoid reflux and that is the main problem avoiding reflux after a proximal gastrectomy

So what is your choice in the anastomosis of proximal gastroenteritis?

What is your choice if you perform a G-sit tumor just as you like?

We still perform a circular that is located in the anterior portion of the remnant of the stomach,

and the wings of the stomach are put like a nascent fundoplication around the anastomosis

in order to try to avoid major reflux.

Okay.

Yes, indeed. Maybe we are all from this, this, this,

including the foldable number of these,

including the surgery of the glasses now,

these methods are all such a development,

so to speak.

They may be more likely to have gastrointestinal disease.

Especially for the patients who are fat,

this will be relatively mature for them.

Because this may be purely related to one thing,

Or, as he said, the GIST will be involved in the reconstruction of the small intestine.

The rest, including our Margin, and our Limadi Qing Sao, won't need to care about these issues.

Anyway, everybody here is congratulating, because this section, that is guided by ICG,

is not only perfect in terms of respecting the surgical plan and the removal of the nodes,

but it's totally bloodless and I think that this is the most wonderful this session we have seen

so far it's very everybody is congratulating in here from Italy yeah thank you

来自所有意大利外科医生的这个祝贺。

应该是这样的吧,班老师。

谢谢,谢谢,Thank you.

This is interesting.

So you are not over stitching,

you are preparing the first string, right?

Yeah, first string, sutures.

可能每个人的选择不一样啊,

他们解释问咱们是不是我们做这个

first string, sutures,我们做这个荷包缝合这个,

It's a very clean, bloodless condition.

It's a portal vein.

Okay.

And then you have to stand between your legs to do this.

Yes.

The surgeon was now changing the position.

He stand in the middle of the patient.

He turned two legs.

The camera system was standing in the right side of the patient,

behind the first system, and the patient's positions have changed, have held up to 50.

So you tilt the patient a little bit in order to reach the splenic hilum.

How do you call those green nodes that you now see in this part of the gastrocolic ligament

there?

Do you think they are the nodes that are adhesion to the origin of the left gastrointestinal

vessels?

higher yes now it's extremely clear the anatomic view is simply perfect

This is the first step for laparoscopic splint preserving the number 10 nipple nose dissection.

We usually call the first three steps.

The first step is the lower part of the splint.

As you see, we revealed the end of the spring artery and the root of the left gastric epiphyte

vessel, and then dissected the number 4 aspirated lymph nodes.

and usually we will transact one or two to short gas check vessels and finish the step one

Could you please explain better this first step?

Yeah, we call it the first step.

Oh, and the first step is from the pancreatic tail, we reveal the load port of the spring

vessels. And usually we will reveal the left gastric epipoint

the vessels and dissect the number 4 SB and then we continue to reveal the one or two

to the short gastric vessels there are green lymph nodes, light lymph nodes in the 4 SB area

There are lymph nodes around the sphincter vessels.

This is a short gastric vessel.

Yes, it goes to the stomach from there.

So you are not planning to do any ischemic splenic injury

when choosing the right vessel to be clipped.

I think it's a be careful the sometimes and the low

lower port outlet will have a bench to the spring.

So Professor Huang revealed carefully

to shield the root of the shorter gas checker vessels.

No, no, no, it's the end of the first step.

The next is the step two.

Step two is from the proximal of the spring artery to the spring hilum.

The main dissection lymph nodes is number 11P and some part of the number 10.

We can see all the lymph nodes with green lines have been dissected.

the system were holding the poster water of the stomach so make the area around the spring

bring up oxaloids clearly.

It seems that we can see the advantage of the fluorescence imaging here.

The lymph nodes is that very much cannot be visible if it is not showing the green line.

It is very easy to understand what is the pancreatic border, what is a vessel, what

is a node.

In our research for RCT, from RCT, we showed if we used the ICG or lymph nodes

dissections, we may average have eight lymph nodes, more than eight lymph nodes.

And the average in the ICG group, nearly 50 per patient.

And if we don't use the ICG, it's around 42 lymph nodes in each patient.

So I think ICG is useful for the D2 lymph anectomy.

me. And importantly, your research also showed the differences between the survival and I'm

looking forward to a longer follow-up for a five-year survival. Yeah, three years. The survival

for the three years follow-up and we found the patients were have better survival after the

because the spleen artery was not straight.

You have a colon.

The spleen artery is so frequent

that is extremely clear in your operation,

the advantage of using ICG in order to grab the nodes

and avoiding to follow false routes and make a mistake there.

It's very clear, and everybody here is congratulating.

Yes, thank you.

so is this almost the end of the step number two or there is still yeah almost done for the step

two is from the spring artillery to in the middle of the spring artillery to the spring highland

The left hand of the assistant is really important.

They holding the posterior reward of the stomach and make his right hand can help the surgeon

to finish the lymph node detection.

This is the third step, the third step.

The third step is the upper part of the spring, and usually they will have two or three short

gastric vessels.

In this step, we need to make the stomach and the greater omentum in the right side

side and make the left upside of the spring clearly.

Yeah.

It's one of the short gas check vessels.

Yeah, the last one, the shorter gas check vessels.

Maybe sometimes it's very short, very short.

splenic hilum dissection as it is now yeah of course a moment in the professor

after the left side of for as for the finished professor one will shoot us how

about after the finished we have leaving those

dissection in the number 10 area. As we can see the spring arcturus, spring

vines, and the lymph nodes around these vases were auto-dissected. There was no

green-lined lymph nodes.

It's extraordinary, wonderful.

In ICT model, we can see if there are even nodes.

Okay.

Yeah, this is the number 10 lymph nodes we have dissected, it's perfect.

you dissecting so high up in the mediastinum without removing the notes maybe because of

we were have an asthmosis in by the linus table i see so you do a linear you want to

reach with the point of your stable where you see it very much

It's easy, it's easy.

来,纱布来,大的纱布。

来,我们这个没有血液的从这边看一遍啊。

没有血液的先看一遍,来,进来。

你沿着这个走就行。

It's the super pancreatic, the liver nose dissection.

And Professor Huang will show us after we finished the liver nose dissection.

change yeah it's a perfect view thank you very much see the portal vein the cava vein and now

the hiatus with the high dissection of the esophagus superior border of the pancreas

splenic island is totally naked totally dissected it's a great operation we see also the anterior

of the adrenal gland there.

Spring vein in here, 11-piece lymph nodes are totally dissected.

And the adrenal gland is right there on the left side.

Yes.

OK.

It's perfect.

Come in, come in.

Come in.

Come in.

I must, I must.

Just like this.

Come on, this, this, this.

Wipe it off.

Wipe it off here.

20 cm

Asperger's anastomosis usually is

about 25 to 30 cm from the

tristigmas

this is a wheelock light

we will shuture the closed the common incision by shuture

Yeah, and totally for the total gastrectomy, the leakage rate is about below 2%.

By this method, I think it's around 1.5%.

I know some colleagues were doing endoscopic just after the anastomosis and are your team

are ever trying to do the endoscopic to check the anastomosis during this operation?

It's not routine method. Usually we will know after we have finished the anastomosis

But if we feel the anastomosis is not so good, maybe we will have an endoscopy to check if they are bleeding or leakage after the anastomosis.

What about blue dye test?

Sometimes we use a blue dye test.

We inject water-colored desophagus and we see if there is some blue dye coming out in some small leakage in order to make it perfect.

Yes, but as I remember, we have never tried this method.

And the most used way, we will use the endoscopic.

Let's see if it's normal, and if there's any leak, and if there's any bleeding.

This way it's more accurate.

If there's no leak, we can also use the air freshener, which is the easiest way.

So for some centers in China, we prefer to use endoscopy to test the anemonesis quality.

15, maybe more, but I don't get to 20, 20 minutes, because I have to do another anastomosis, but these go like rats, so.

And Dr. Diago, do you perform the robotic surgery for gastric cancer?

Do you perform robotic surgery for gastric cancer?

Robotic surgery.

Well, we are moving towards robotics every day more.

The problem is that we still have, you know, some financial problems,

but we still believe that in order to achieve precision surgery,

robotic can be a definite addition to our quality of surgery.

Of course, when we look at an operation like this performed by you, there is no need of adding anything.

It is so perfect.

But, you know, especially for a patient that has high body mass indexes, robotics can be different.

And following your operation, I will present a presentation of mine on this screen that is entitled,

How We Teach Robotic Gastrectomy.

so we have courses that are needed in order to overcome the gap of frequency this operation is

not so frequent in western countries so surgeons should have an accelerated learning curve and

and a small case volume and i think that teaching robotic gastrectomy can be one of the possible

solution in order to overcome this volume gap so do you think robotic surgery will replace the

traditional laparoscopic surgery, if we don't care about the financial problem?

Sorry, I think that maybe not these platforms, but the next generation platform will be totally

integrated with AI. So robotic will give you a virtual assistant, suggestions,

and you know superposition of radiographic images of the patient. So many possibilities

possibilities of improving and virtualizing your gesture that possibly it is yes I don't

know when and how but I think it's going to replace our traditional laparoscopic approach

okay

so this is what we call Omega Loop reconstruction

They are performing another burst string, right?

Yes.

Are we doing a bag?

Yes, we are doing a bag.

Okay.

From the back, the front, the back.

What is more suitable?

Actually, we did a discussion about the delay that decided the small bone to do the anemosis.

Probably this procedure is more for the for the high BMI patients that should be more better.

这个白钉在哪一个?

这个我们做到45的地方

现在这个是20

两两次

This blue line is 20 centimeters

Usually we will have the genital anastomosis

apply ERAS techniques to food rehabilitation? How many days do you wait before giving oral

food to your patients? Usually it's 3 days post operation. Yes, we use the faster chat

chat for the patients after he have the password we were made he have the food

great food and yearly is five days most operation to have semi fruit okay so

what is your average discharge day how many days in average they say total total

Total gastrectomy is about six to seven days, usually it's seven days.

Some younger patients, maybe six days will be okay to discharge.

And what about the use of drainages?

Are you using tubes for draining these patients or no tubes?

We use two tubes in the left side and right side around the first anastomosis.

interested in in measuring you know the it's evident quite evident the blood loss is almost

zero what is the average time of operation from from first stroke to wound closure the average

time for operation? Yeah average time for your operation. I mean you're very

fast and perfect and it's almost bloodless so I'm curious to know what is

your average and what it can be done. And usually average is around three hours.

Three hours. For the distal gastritis sometimes around two hours and the total

gastrectomy maybe uh two two or two three hours for one case uh today we have uh arranged uh

fourth gastrectomy uh in in this operation yeah it's the third one and we have the

the first one after this operation.

Thank you so much.

It was great.

So four gastrectomies in a day

with an average below three hours.

It's great.

And I didn't know Western surgery

is able to do like that.

So congratulations, Agreen, from Rome

and from this wonderful...

That is just the one operation.

We have the other one operation

to have the other for the gastric cancer.

So today, Professor Faustin,

we have eight operations.

what everybody is telling here is that the surgeon the master surgeon is a master is great but the

team is perfect the team the way you work together without no instruction they are perfectly

synchronized and every single step has been performed after preparation we have seen it in the

number 10 this section of the splenic island during the anastomosis during the

do the you know preparation so it's great thank you again yes thank you i agree with you i think

professor kwan uh have to make our team to perform the laparoscopic surgery since like uh he's he's

stalled and when professor zhen uh i have i performed the operations like the professor

once stalled and so maybe it will be faster and useful especially for young

surgeons I think professor is some sounds is as the first step once the

three steps for the spring high lymph node dissection.

Professor from Italy, Professor Huang, have finished this total laparoscopic total gastrectomy

with three-step spring-high lymph nodes used by the ICG guide lymph nodes dissection.

We thank all the audience from all over the world and thank you everyone from Italy and from Chinese experts.

Italian experts have already seen our discussion.

We hope that in the future we can have more opportunities like this to learn.

Thank you.

Thank you, Mr. Huang.

Thank you Professor Chao and Professor Jianxian for inviting us.

We learned a lot. It was very exciting. Congratulations.

Thank you, Jianxian. Thank you.

Thank you.

Goodbye.

Goodbye.

Goodbye.