BONI EMICOLECTOMIA destra

Okay, good morning everybody again. We are on the second case. She's a lady, 76-year-old lady.

Past medical history, she's suffering from a minor thalassemia and she had a previous stroke,

so she's on aspirin therapy. She was admitted today in emergency and accident to the department

not long ago, complaining from asthenia and lack of breath.

They did a blood test, and she had a 5.8 gram pair of hemoglobin.

So they started to investigate the reason for this anemia.

And so she had an esophageal gastroscopy that was negative,

and a colonoscopy.

She had a lesion at the level of the ileocecal valve,

and the biopsy of the lesion was adenocarcinoma.

She had a preoperative workout with abdominal and chest CT scan.

There was negative.

Cannot see much on the CT scan.

Maybe there is a thickening of the level of the cecum.

She's very thin, so in one sense, that's very good.

In the other sense, it's not so easy to find the right plane

when the patients are so thin.

but we are surgery we're never happy about thin or fat people so we are to cope with that for

sure better patient like this than a very big patient so now we already put the trocar uh and

the po2 can we increase the co2 the plamo peritoneum so this is my trocar setting okay

there are i use four trocar there is one silver public for my left hand there is one that is on

the dune is here the pancreas is there and you can see very nicely the

idiocolic vessels over there so my assistant today is dr. de la porta and

Ludovica as I mentioned as our resident and the team is the same as before can

have the hook in China okay the plan is to do the standard

right laparoscopic right colectomy with CME and if we can get the light off in

the OR so that's the idiocolic over there so I guess that the superior

mesenteric vein it should lies on here actually you can the patient is so thin

that we can actually see it so I started this section with a hook I like the hook

for this part of the operation because it's actually give me a little precision

decision we switch for with an energy device later on so my plan is to

identify the superior mesenteric vein and then follow it up okay we swap with

the visual system we now using the stores camera with the ICG capability

we will check the perfusion of the of the colon later on so this is the

the superior mesenteric vein over here.

So I'm gonna try to find the iliocolic vein

entering the superior mesenteric vein.

And then I will follow the superior mesenteric vein

to find the way to the middle colic.

And eventually if she has,

eventually also any right colic.

Okay, let me just grab here.

Okay, I made a little bit of bleeding

just to show you up where the vision was max can you just okay okay just push

down the superior mesenteric vein okay can I have the suction because I made a

little bit of breathing suction please can you follow me please thank you okay

I need to move a little bit okay so this is the root of the superior mesenteric

vein I will make this bleeding stop in a minute so we'll connect the bipolar

bipolar please and this is underneath the superior mesenteric artery over there

okay if i can stop this bleeding you will see much better can i have the bipolar please as i ask you

i don't have the pedal for the bipolar

it's not working

No, no. Hardcore. No. I don't know. It still doesn't work.

Okay. Give me a little bit of Thunderbit, please.

We need to... Maybe we'll try the instruments first.

Okay. We'll use the Thunderbit anyway. Stop this small hoosing over there.

Okay. No problem. Okay.

Can I still have the hook? Okay.

Put it a little more horizontally, Max.

Okay, so this is the entry of the iliocolic vein into the mesenteric, superior mesenteric.

Now we follow up the throat.

Okay, we'll go a bit closer.

There are some lymph nodes over here, but I don't think that they have any meaning.

They look so inflammatory.

Likely we have an artery that goes underneath the superior mesenteric vein.

The iliocolic artery goes underneath.

need so we'll have to take the idiocolic first the artery is probably here as you know there

is a great deal of viability on the position of the artery compared to the vein can have the emo

please and the thunder bit i just placed an emolock where i actually gonna leave there and

then i will rely on thunder but this is a small vessel

Now I'm going to look for the artery in a minute.

I'm just dissecting a little bit the superior mesenteric vein from the mesentery.

I need to go a little bit here.

Okay, this is the plane.

Okay, this.

Okay.

Okay, you can see here the artery, iliocolic artery.

Of course, can I have the hook?

We're not perfectly on fire, but Max, okay.

down the pancreas and the duodenum that is going to be somewhere here, pay attention

when we are dealing with such thin patient just to try to avoid to break

the mesentery. I will stop a second here because I want to follow the superior

mesenteric vein that is over here as you can see. Okay I need to detach here okay

and I will try to find my way till the transverse colon. Now gonna look for the

the very origin of the middle colic,

because it's a tumor, it's a tumor of the cecum.

So I will be happy if I can find the right branch

of the middle colic.

Okay, I'm just turning towards the transverse colon,

trying to avoid to enter into the mesentery

of the duodenum.

That here is very common because the stomach

and the duodenum are pushing against the mesentery

of the colon.

the center of the column is this one okay let me see if i can find the vessels okay

need to be patient because here with this instrument now i maybe as well coagulate the

middle colic without even seeing it i would like to show you okay very likely i can feel something

here see what we have let me push down the pancreas here okay okay okay very likely the

this is the plane as you can see here transverse colon is here and then and this is the middle

colic not this one but just behind my okay artery middle colic arteries here

to be honest with you i would like to keep the left branch if is if i can see it once again here

there is a really a big deal of variability in the anatomy of the middle colic so if i can okay

otherwise i will just take it here okay can you take me away this part with the scope

okay i think that i think we just have one branch here and i may have difficulties to find the right

branch of the middle colic let me have a look properly let's see and there unless she's

dividing i think the this may be the left branch because it's going this direction

and the division is a little bit earlier okay i will stop for now because i want to complete the

mesocolic dissection over there okay here yeah so that is probably belongs to the pancreas here

there there okay let me finish here because when you have such a thin

patient I don't want to lose my plane that's the pancreas and that is

mesocolon try to have at the end of the procedure we try to see if we if you're

doing well we would try to show you you know how it looks the mesentery of the

colon for a total for CME for a complete mesocolic excision that they should look

not triangular but should look a little bit more let me just make it in a in a

square shape difficult in this thin patient see if we can find the right

plane here okay because here it actually gets really thin I don't want to break

it some online okay we're back online we had some problem with the connection but

it's been let me just check that we're not doing too much okay okay okay okay

some more line okay okay I'm trying to detach the duodenum this is the right

plane and this sector told fashion without breaking it and without entering

the kidney that when the patient is really so thin it may be a problem okay

okay let's close it and close it okay carry on like this pushing down okay down down down and

down there we go okay okay now we're pushing down the head of the pancreas the duodenum

okay this is the vessel that i need to take so i'm going to place an hemlock

here okay i'm going to take the artery and the vein at the same time doesn't really matter in

this case max show me better and then i will at some point to move above the transverse colon

cutting the the momentum okay stand a bit okay now we're going to move here

there is the round ligament that is on the way okay now i push this down again and again okay

we're gonna go above okay i will ask ludovica to grab the momentum over here

here and now we'll grab the transverse colon and we'll try to join the two plane then i usually

cut the transverse colon because that's helped me out a little bit with the mobilization of the

hepatic flexure i'm gonna do a intracorporeal anastomosis and i'll pull up up okay i need to

reassess okay ludovica like this not this but like this okay here and here and i should be able to

the rest will come with me, it's a small lesion, so I don't think there should be an early stage,

it should be, okay, so this is almost the dissection we've done medially, okay, let me just check

a second from below okay it's almost done here we need to I will clean the

camera a little bit because there is some fog okay okay let me reassess here

because there is a little bit of redundancy into the momentum that is

it's here okay okay max close it okay okay so where I have to cut okay let's hold it like this

I need to cut this part here and to finish here we go so that is my the mesentery of my transverse

colon okay so now you need to pull down a little bit here I need to pull down a little bit there

i want to go back because i want to cut i need just to check one thing on my mesentery because

i think i need to cut in here and i still have a little bit of mesentery too it's a bit of redundant

transverse column but will make our life easier when we have to do the anastomosis

okay hold this like this okay kind of it and we're gonna prepare the stapler so that's where

my division is gonna be let me just find the best way to cut okay here i think we are gonna use the

as a stapler the device from johnson and johnson that is an automatic one and it's got a very

having any slippage of the tissue I'm gonna use the gold cartridge and we wait

few second to have the edema to go away and then we're gonna fire okay out okay

now I need to finish my mesenteric dissection put it like this

Tandavit Tandavit okay and then I will go back to the terminal allium because

because I haven't finished the section of the terminal allium,

and also I haven't finished the told fascia, if I'm not wrong.

Let me get pushed back there.

Okay, hold on.

See that here is still attached, need to still pull it down.

Max, like this, and like this.

Okay, I'm just going to cut the center of the terminal allium

along the iliocolic route that I'm actually grabbing now.

i guess yes that's the idiocholic yeah not to go too wide okay let me just okay so okay so this is

you see the terminalium is a little bit posteriorized we can do like this down

she had an appendectomy in the past i cannot see the appendix a little bit here okay let me just

stop a second get the wider view because i am a little bit too lost so transverse colon is here

middle colic is there heliocolic is here okay i think we need to widen a little bit

okay teeny okay like this okay that's a heliocolic time a bit a second i think i need to

dissect here, because that is the right plane, otherwise I'm going too deep here.

See, this is the complete embryological plane, so we have no much bleeding. Okay,

we prepare another stapler for the terminal ileum soon. Okay, okay, I'll push

this down. We are on the other side, stapler. Just ask Ludovica to grab the

terminal allium so is a little bit more stretched that was my fault okay give me the thunder bit

first i need to get a little bit of a more static okay now i need stay still like this

this addition and the terminal volume were quite convenient for now we will divide it later so

So I don't have the terminal allium to go everywhere.

Can you show me?

Yes.

Okay.

Of course, I need to mobilize for the anastomosis,

but I will keep it like this for now

so it will not twist and go all over the place.

Anastomosis.

I have to put it in the blue.

Hello.

Okay.

So now we finish this part like this.

Okay.

a little bit and let's need to push down a little bit here refocus okay push this down down down go

up down down down okay like this okay now you need to pull like this down there pull ludovica pull

yeah okay wait wait calm down okay stop we go back keep this down we go back to the transverse colon

area I think that it's just a little bit left yes no the appendix is there hold like this

stand a bit I'm gonna get a suction a little bit just to suction okay now we are gonna just park

Mark the specimen for now over here above the liver, okay, suction, suction, okay, this

is the transverse colon, redundant, as we say, but which is good.

Come here.

Bipolar, un attimo.

Bipolar.

Ah, funziona, si?

No?

C'è, ve l'ho dato indietro prima che non funzionava, me lo vi date che non funziona?

it's not a big deal anyway okay let's do like this so this is the colon this is transverse

okay can we get ready for now with the uh icg

okay okay let me have a look here max please okay so this is the superior mesenteric artery and vein

up here i think that is the middle colic i think is the right branch because the left branch is

very short common branch of the middle colic and you see that's the left and this is the

right this is the pancreas trudinum and now i'm gonna find i need to mobilize here the

terminal allium that is attached to the rate of peritoneum sometimes it does happen

i need just to mobilize it from here maxi you know this customer versus okay

lo facciamo. Me lo spingi un po' dentro. Okay. Here. There. Okay. Adesso mi serve

più. Okay. Okay. So now we can, first of all, mettiamo il paziente dritto, non più

turned towards me hello hello professor boni yes hello I am mario panzera here from rome and I will have the

pleasure of commenting on you wait give me two minutes that I arrive in the classroom so I can see the images

ok ok perfect I'm almost done but I have to do the anastomosis but it's ok there is not even

you sometimes. Yes, it's here. Say hello to me dearly then, ok. I feel very bad about this. Wait, wait, wait, wait, wait, wait.

We worked together. We worked together, in fact. But you can also come back soon, it's not a problem.

Ah, well, but the problem is that I can't find myself anymore. What did you do? A right microlithium? I did a right microlithium,

yes, now we prepare. The bed has been put straight, yes? Ah ok, no, it's fine like that. Ok,

Ok, can you give me a moment? Let's do the green one in the meantime, come on.

We're going to check the perfusion with the ICG, also two, look.

Here you this, since this morning I moderated a round table and there was a lot of use of green.

Yes?

Do you believe it? Do you not believe it? Why do you do it?

Well, let's say that I do it practically in all cases, I believe in it enough,

both on the collecistic and on the colon, we have published a bit of our experience,

then we are doing a randomization with Sarafei, the results are very very favorable even if

we have not yet demonstrated a statistically significant difference, but we have half

of the anastomotic sciences on the left column and on the rectum in the florescence group versus

non-florescence so I definitely believe it now I was looking at this noise ok

so for me the technology from this point of view here is very winning and at low cost

above all and exactly this is the principle I get information with a low cost and with a

let's say so without zero difficulty of course ok now it gives me a chin ok more tags all

the two curves of course sure and for nothing they can not serve me important ok image that you

we do an isoperistaltic anastomosis yes ok a lateral lateral ok I am now a

few years that I pass that I do the intracorporeal because it exclamates a series of

advantages yes this aspect has been widely debated

all this aspect? 3-0. Ok, 1 to Uncino, yes. And how do you find the Policlinico di Milano? Very good,

very very good, apart from the fact that I couldn't say otherwise. Of course, I asked you the question on purpose.

But even without false compliments, very well, they know it too. Sure, sure. Give me a pinch for a moment,

then try to do most of max but so I can't even work you should put

your hand on mine in your arm ok perfect very good go first to do the most

here I am in place but I have to do the most here because there is a base here about the uses of the

various ultra sound devices etc. etc. etc. you also say your opinion

I was born with the ultrasonics, so I struggle a lot to use the advanced bipolars,

even if I appreciate some things of the advanced bipolars, so from that point of view,

let's say any improvement, but it is also true that from my point of view,

l'uncino e bipolare sono gli strumenti migliori e gli strumenti avanzati hanno secondo me

paradossalmente sono molto più utili quando si ha una certa esperienza. Certo, ti sto seguendo

perfettamente. Mentre invece all'inizio almeno i ragazzi giovani che lavorano con me gli obbligo

diciamo così a non usare soprattutto all'inizio gli ultrasuoni perché creano o gli strumenti

advanced because they still give me they can create let's say that they forgive the errors of the

plans then since the oncology is a very let's say so anatomical surgery is very

excessive here and it is very embryological then in my opinion the monopolar is still a good

especially at the beginning, then when you slowly find yourself well, in my opinion, you can also

pass an instrument. Now here at the Anastomosis I did the blue charge, as I said before, we use

this device from Johnson & Johnson which is a robotized system, let's say so, but the advantage

which has this anti-slip system of the tissue

so that once you block them they do not move

this is very useful, in addition to the fact that the robotized one

when the action is perfectly still, it does not enlarge the enterotomies

This is really in these anastomosis, in anastomosis of the gastric esophagus, in the anastomosis...

Yes, yes, there are no possible tremors or bandages of the hand when you shoot.

Exactly, these are always very hard.

Here, I believe that...

Ah, ma'am, you see that we do not prepare the patients for a low-resilient diet, ma'am.

now I close with two points two continuous in valkyrie there was yesterday a sort of

small discussion on the closure of this residual breach with a mono layer two layers you

how will you close it I always close in two layers two continuous I practically make a point

here and then another point on the other side and then he gives me the other portaghi the reason

what is it is a very scientific reason in the sense that speaking with riccardo rosati

but at the beginning there is a single layer I had a bit of science ideas from when I do

but this is also the idea of ​​corcione that he expressed yesterday then I said who am I

but then here there are those who use the self-locking wires and another possibility

but I don't think it really does on such small enterotomies I don't know how much it really makes

a big difference of course but then there is always that of atriba that they are not recommended there is

on the intestinal structures, so it could be who knows never. I think the Americans are strong

because instead of taking on responsibilities they write about everything. They tell you if you want to use them

but they use terms a little sibilini. Ok another continuous. You know that I am very

friend of rosati who is a great surgeon but a modest golfer but I don't know if he thinks about it

the same way as not having played together from time to time if sure but if the

mena a lot on this golf but to bogogno if I'm not mistaken yes yes but you know who can

permette come lui è certo ok questo è forse il punto sempre un po più sì però è un punto

fondamentale che poi ti permette di fare la struttura bella diritta calibrata bene che

non sia cartoccia per cui secondo me dal punto di vista didattico e vava rimarcato questo passaggio

perché poi se ti lasci anche i capi un po lunghini poi trazionare quindi ti viene pesato

now I do this then I go back there because I find it easier to go down towards me on this

I had a discussion the other day just last week I was in asia with barry sulky of new york

instead he does the opposite he says that it is easier for him to move away I said but I don't know

it seems to me the first time I hear it as an idea is much less comfortable as an idea in short

now let's take the other wire, so you leave the point and then you continue with the

wire exactly and then with this continuous I tie it with the other and with the other then I go back

I tie it with this, so these are the two wires with which I would make the two sutures

the first and second layer, so there are not too many wires that turn in front of your eyes

Max, give me the zoom, now that there is no longer need for fluorescence.

Well then you are very good at working with Max.

Well yes, sure.

It is an added value of difficulty to laugh at.

But you know, Max, like all those good at laparoscopy, he does not know how to keep an eye, but he does nothing, we forgive him.

But I know it perfectly because I recognize it in me too.

Let's say that his master made him work too hard.

How many trocars are you working with? With four, in this case here you could also do less than one because the lady is really very thin.

Now Ludovica opens the corner a bit, so I'm sure I took everything.

Portaghi, where did you leave the portaghi?

So I'm right hand, left hand, optical and then the assistant that in reality I use to lift,

mainly to lift the transverse colon.

Sure.

The patient is supine.

I showed the CME before, which was pretty good, even if these cases are so thin, I said,

they are very simple, the intervention is simple, but then respect the anatomical plans well,

but you always start from the preparation of the vein I always do yes I go

I take the Iliocolic and from there I find the superior mesenteric vein and remove everything that is

on the right of the mesenteric vein exactly exactly ok now I take this now I

tie this continuous I tie it with this I let go now Ludovica is an excellent quality

of the image is a 3d you use in operation between no no no this is a full hd icg of the stores

but I have to say that I think the quality of the image is very good here but I think you

see it very well there because we have a very very good connection we are connected with

the olympus room here it is just multi multi brand connected with the university guard network I think

that really but it is one of the best screens in fact in this orgy of surgery that I have in front of my

eyes ok give me the scissors for a moment this is the cut and then I start with the other one and I make a

second layer both or I use much faster no no no I do not use the 4k but I use the 3d but because

Because I am one of those 10% of the population that does not perceive 3D, so it only bothers me.

It disorients you instead of helping you.

Exactly.

Exactly. While before we did the Surrender with 4K, on 4K I have a lot of benefit because it gives me the same 3D effect, better than what I usually have with 3D, and let's say that the quality of the image is fabulous.

now I give a little just and just for no to repeat what you would theoretically do

openly in short let's say yes exactly exactly I believe that I always say I do not believe that

it should be I have not started with doing a story in your corporea as practically almost

no one but I believe that it is part of the final learning curve and the nastrosi

because I really find it, you will never go back, even if they told me, apart from the fact that now in literature there is some evidence, a little stronger, recent, but even if they told me there is no difference, I take it more simply.

But I believe that what Corcione was saying yesterday is the sum of this speech here, if you do the extracorporeal anastomosis

you make the parotomic an laparoscopic intervention, instead of doing intracorporeal it is a real laparoscopic intervention

in the sense as an outcome of the patient, as a channeling, as an advantage in this sense.

yes yes sure then in short apart from that I always do funnesty but in this lady here you could

do a transvaginal extraction for example that in this case here for a right colon in an

old woman you really do a colic resection with the same number of accesses in which I do

the colicistectomy here it is finished ok but what end has the nut made the nut is still because if

the money of the industry is over they threw away a lot of money then now I don't know

we will see for sure he did some he gave some advantages especially for me to breathe he gives me a

sacchetto poi ha dato qualche vantaggio secondo me sulla sullo sviluppo di alcuni elementi

diciamo alcuni endoscopi alcune innovazioni endoscopiche perché qui ci sono buttati mi

dà un attimo scusa il tango e devo capire questo pezzo di aumento qua che credo che

sia quasi tutto max menti questo lo taglio messi sto pensando anch'io quanto sia vascolarizzato

here then another question closes then after the mental break no no I the month

no I do not close it anymore because in my opinion when you do the cme you really leave one

that is the hole you leave is very very wide and let's say that I enter a

and in reality I would not want this to be the case because I have never had problems.

At the beginning I closed it, but in my opinion I did not do such an extensive lymphadenectomy as the one I have now.

I don't know, I don't close it anymore.

Ok, so now let's take the bag, then I, well, this is the congress.

Usually I do, in the right colon, where usually there are slightly larger tumors,

I tend to do the double protection, that is, I do the funnesty with the wall protector and I also put it in the bag

because what happens is that we continue to make all these smaller and smaller cuts

and therefore, even if you protect the wall, the idea of pulling on the colon, passing through the wall,

of crushing all these tumor cells inside the belly, I don't really like it, so I do a double protection.

they have reduced their costs so let's say that we can but this is a big bag

if then he could also give me the troca because this is inside the troca, he must also give me the

chuck, he must here every now and then change the bags, ok, he gives me the bag, I don't have it inside, I don't

leave the drainage because I don't see that it serves anything, especially in this case he gives me a clamp

Also because I would leave more drainage for some bleeding, so in the right colon I think that drainage does not give any advantage, but not even in the left, in terms of anastomotic issues, if the patient is not well, my attitude is to be, let's say, a bit tolerance zero in the post-operative, there is a colon of the parascope that must go really well, well, well.

Exactly, because it happened to me, of course, like everyone else, I also have my complications, almost all made by Max, of course.

Of course, I didn't say it because it almost seemed like I was going to puke.

But wait, because I don't know if he came in, no, he came in too.

And in reality, I think that if you come in immediately, very quickly, the patient can be approached by laparoscopy.

Sure.

and really alters his post-operative course, that is, he is really active, he is inside for two more days.

Sometimes, in some cases, on the right colon, it has happened to me in small descents,

maybe of the enterotomy of repairing them, washing them, draining them, not doing any

lidostomy. Here it is fine, now we turn off the CO2, we go out for a moment,

we do the FANNESTI, we protect the wall and then we are done. Then for today you are finished, do you have other interventions?

We have a MILSA afterwards, a splenectomy for a Verlof tumor, a thrombocytopenia and then

we finished well you made a program if it is a rich program ok I do not know if we want to see

from the outside it gives me to infiltrate the wound a little you can see something from the outside yes you can see

maybe the bag what you see now you can see the room yes yes ok I don't know if you can see

to see because we are a little far away with the environmental camera here I make a small fan

and then in these moments here it is very elegant to present your collaborators we have already done

anyway apart from the door teacher who is certain that I see him from behind there is the

doctoress baldari who is our specialist of the speciality school at the third year no maybe

Yes, it's the third year we've been promoted.

Then there's Elisa, our day's instrumentalist.

Anyway, we're also guests, actually, because unfortunately we had a problem with our room, so we're in urology.

In fact, I remembered a room much more technological than yours.

No, but that was the one in Varese.

If you see the one from now, you put your hands on your head.

But we have finished the new ones that are very beautiful, even more beautiful than those in Varese.

Of course.

But we still have some problems with accreditation.

I hope to be able to do it in a while.

The urologists have been very kind.

Ok, now.

Ok, now I'm inside.

Ok.

Wall protector.

of walls you can give me a little light for a moment because I can't see well I can't see but I'm not

inside I still missed a piece of peritoneum however I must say that palazzini is really

a great one even the sponsored hat is the most I don't see guys I have to have

Fababef worthy of this name because these here are nothing, no no wait because you can't see anything here

there is the muscle, the muscle, oh you see that it is open, it is open, ok give me some Fababef, sorry, sorry

because there is a hole, I heard it, ok give me the wall protector, ok, the protector here I need

just also to do a little as a dilator, sure, sure, yes but you have to leave it, no because the other thing is that I want to do it

For all the years, I do not envy him particularly.

Okay, okay, now keep the pieces out, okay.

Close for now, thank you.

Thank you all very much, see you later.

Thank you and see you next time, okay.

Good day.

Goodbye, have a good day, bye bye.