M. MORINO gastrectomia sub totale

So for the moment we don't have a chairman, but we go on with the procedure for a low rectal cancer.

When we will have a chair ready, we will present the case with official slides,

but it's a tumor located at six centimeters that was treated with neoadjuvant 83 and plus treated by neoadjuvant.

so we have started a few minutes ago by opening the gastrocolic ligament and now

you see here this is the Girota fascia this is the renal the kidney renal

kidney vein and this is the spermatic vein so we prepare as much as possible

from here we have already and here you see this is the pancreas you don't have

to go below this because you are you will go behind the pancreas you have to stay here but

i will do it from from peripheral okay so having done this this section we stop here

we mobilize a little bit more the flexure so in fact i'm doing a sort of mixed approach

partially sent central to peripheral and partially external to medial this to speed up the procedure

and we use essentially monopolar once again to speed up and to be more precise

Damina Joanne, completiamo qua, tira giù così, prendi pure, we have still some connection here and here

Ciò qua qua che non va? Eh? Ah ok. Oh this is the gerota and this is the splenic flexure

Trendelenburg and it's tilted to the right so toward toward the surgeon he

will remain tilted to the right for all the procedure that means in Lensil while

the flexor but it's not descending these are two different things I think it's

very important one is to medialize one is to lower to lower you have to detach

it from the stomach and the gastrocolic ligament otherwise it will be medialized

but not lowered pancreas you see here so I don't have to go there but to stay

and medialized

okay so now we start looking below we need to clear the pelvic from the intestine the

small intestine it's some liquid that it's an in a male is strange not too

much maybe the radiotherapy the patient had 50 gray of radiotherapy and chemo

that were ended at the end of September and now is 10 weeks after the end of

after the completion of neodymium treatment sputum so now I medialize I

I mobilized and medialized the sigmoid.

non ti lasciano neanche mangiare senti allora ti faccio sentire il caso allora

noi abbiamo già fatto qualcosina un retto basso il dottor giraudo lo

presenta c'è di nuovo l'eco e c'è di nuovo l'eco

abbiamo di nuova ripetizione come prima secondo me è quello che sentono in

streaming that I hear it a minute later, it's not that, Beppe. Try to repeat it, I was filming, let's see,

probably it's the streaming, you're right, but you had told me before that I have a rectum, how many centimeters?

Yes, then I say in the meantime, then we see, at most you hear it twice, it is a rectum measured at 6 cm in

in rigid rettoscopy that was studied at the end of September T3N+, with an invasion of the mesorectum

and therefore it was directed to a neoadjuvant 50 gray and chemotherapy that ended in September

in short, which ended at the end of September and 10 weeks have passed since the end, which is more or

less that between 8 and 10 weeks is what is currently recommended to wait, it has had

an extraordinary response, it has decreased a bit but not so much, it is a very interesting case for me

because it is the border between the TATME, therefore the approach from the bottom, and the classic TME. I

I do the low approach not so often, I have been doing it for a long time, long before it became so fashionable,

but only when we do a colonal in the line of the maximum, or in very fat men.

This patient has a BMI in the norm of 23 and the lesion is more at 7 than at 5, let's put it that way.

and I have the impression, after a careful retinal exploration with the sick person who fell asleep,

that a good intervention from above can be done. So for the moment I have not started

with the dissection from the bottom.

Yes, he had a chemo radio.

Did the lymph nodes change?

Very little, at least the volume of the lesion.

On the lymph nodes, I am not very clear, the resonant is not balanced.

I'll show you what I've done so far.

We started by opening the gastrocolic.

then we identified the mesenteric vein and prepared the posterior plane to the vein and then

combined by completely mobilizing up to here the flexure the vein but it is not yet cut

now I am medializing the colon a little bit which I prefer to do before tying the artery

because I find that it is faster and a little safer at least in my hands to find the ureter

that we will soon have to see because we are in the area. Here it is. The urethra is here, it moves well

and this continues to be the white of the Thold band, which above is the Gerota band, so the plan is

the right one. Now we can go to the other side, maybe I'll go a little more. Ok,

Let's go to the other side, if you give me a Joan. Now there is the small intestine that goes a little between the feet.

I always start with the mobilization of the flexure because even when there is a Dolico Sigma I prefer not to do, if possible, the anastomosis on the Sigma.

In this case it seems that there is a quite long Sigma.

can you turn it a little more towards me the sick man as mentioned before you arrived

turned towards me as you can see well the urethra on the other side and it is in trendelenburg

give me the vacuum cleaner that we remove that little liquid and at the most ok no no no right

question to do the high part was flat ok at this point we spread the

two tweezers the rectum and I cut in the lower part because in my opinion here is the point where it is

easier to find the right plan, the so-called holy plane, which corresponds to this avascular area.

In patients who have done radiotherapy it varies a little from one case to the other, sometimes

there is actually an edema that makes it almost easier, in other cases not so much, let's see

a little like this time here the plane is clear instead here a little less let's go and look for it on then

then you can help yourself family from the plan that I have already done on with this plan here which is the same

but high mesenteric vein hop so here is the mesenteric vein that goes towards the garden and here

is the artery are a little lymph nodes around now I try to combine the two planes I would say that

the artery is there, let's see from here, you have to pull well, like that. When do you prefer to do the vascular ligation?

Excuse me, I didn't hear. When do you prefer to do the vascular ligation?

It's more or less now, that is, now I do a mobilization, I don't do it, let's say, immediately,

I do a mobilization to stretch well and then I go to bind the vessels, so I do it now,

Now, usually before the artery and then the vein, there was the famous no-touch technique described by Turnbull who said to bind the veins first, but in reality it turned out to be something not only useless, but perhaps even negative.

I think the artery is in here, but I have to find the plane well down here.

And you bind it to the origin?

and I leave it at the origin, let's say one or two centimeters above not to risk the plane of the nerves

veins there should not be there, so there should be the vein

try to leave a moment that I wouldn't want to be too low leave your grip for a moment

I help myself a little more from here because

usually I open immediately there but this time I couldn't

find the plane immediately. It is more careful to go here for a moment. Here we are. I don't know what that

giant vein we saw there is. Instead, here you can see the fascia very well, which is this one that

must be over there, the urethra there that moves. Yes, here there is that vein that I don't

understand. It should at this point be part of the middle. A little unusual a vein like this, but it is

evidently from here ok let's go back from there hold like this and let's go see here go close probably

this should be the sigmoidea and there behind there is the urethra there are giant vessels but you can see

well this is the vascular plane that continues down and up so we are right

turn a little from below that is the urethra we go back up so this is the sigmoidea with a lot of

vein that we go here and here there are the other two planes so this here is the

plane of the vein which is different from the plane of the artery if one of the few situations in which

the two veins artery make different paths are quite lymph nodes here there is a lymph node for

a low rectal tumor a lymph node here is not so much that it has enlarged here it is not a

a nice thing and here we are arriving on the artery but it dries up a little less well than other times

but no one should anyway now here I have passed behind you see now I am in the

safe plane I am very high to let go of the nerves and I bring myself to the origin of the lower mesenteric

and here there is the same plane as an artery you see one and one two as a vein sorry

Do you always prefer the spatula rather than the endosil?

Yes, when I do the gastrocolic, those things there, yes. When instead I have to go on precise planes, I find it faster.

Here, however, let's be careful not to break the vein, the artery.

Give me maybe the crochet and prepare the clips.

ok here we are at the origin of the artery in reality it would still go a little higher but I don't

think there is a reason for it unless the left one starts here if it starts there the left

then it is better to go below the left is a young man so he has no problems of it seems to me it seemed to me to have

seen if you see that there is something below these are not the nerves because the nerves are below the

the artery not above and here you see here it starts on the left to have a good

descent it is advisable to go below only in cases of people with vascular problems

etc. it can make sense to keep it give me the

passers-by I have to lose weight now if I lose weight a little more because if not

but yes in my opinion if you clip then it is better not to use energies because at that point you can

burn a little but you can also use that also because multi-use scissors cut

really little then after this you put the help clip in this window you pull

up like this, thank you, and the dissection of the meso is completed from the bottom, there is still something

that jerks here, give me the crochet, no no no no, the one before, the meso of the descendant, let me see the

plane of the vein, here I have to combine these two planes, here it is, it has gone, ok, pull up Elettra, pull up

also you yes now I also have Dr. Arolfo Dr. De Matteis here we have almost completed

the here you can always see the gerota well obviously we had already done almost everything before so it remains

only more than there is always the vein in continuity that makes this together a bit solid and

allows you to pull and mobilize well all the way here we saw before you

get well from under the pancreas and that there that there is pancreas and then we stop and

then we can go to tie the vein the vein it is important to tie it before the branches that

then go a little more straight like this here before this branch here so that it

from the triathlete, let's say. I have a moment to bipolar here, so triathlete, mesenteric vena

inferior, wires, thanks, go with the clips. Here I put two clips per side because in reality this

lump remains inside. This binding, as Hilde says, is called division of convenience, it is made

to lower the colon, not for lymphadenectomy, which here we are super high, it is no longer necessary,

so the vein will then be cut a second time more more on the same level I give myself the

lens and more on the same level of the artery and that lump there remains inside but detaches from the

pancreas and from the duodenum ok now let's see if it remains to do something on the side close no I would say

but maybe there but you can see well the pancreas released no I would say that it is fine ok let's go

to do the time of the rectum exactly yes here this is the nerve I think spatula yes this

here I think it is the nerve we see it well then after putting the interaction is fine we take

to the right if you have a joan di ly now we see because at the rectal exploration I had the impression

that the lesion is not low but you can reach below but that it is very fixed

posteriormente spero di sbagliarmi tiene aspetta ok manca ancora un trocar perché poi mettiamo un

trocar per sollevare la prostata e la vescica adesso con la pinza dell'aiuto che spinge in

su e la mia mano che spinge in avanti e la telecamera un po di fianco andiamo qui nel

piano questo piano qua dobbiamo cercare di stare in questo piano a vascolare e qui c'è proprio

here you can see well, this here is the nerve that then gives some posterior branches and that must

remain down. Let's see on the left, let it go too. The beauty in my opinion of the

monopolar is that compared to the others it does not create a plane but only helps the detachment of what

that we put in traction, showing that the TMA is a whole intervention with a vascular plane,

if it bleeds it is because you are in the wrong plane. Ok, I think now we have to move forward in a while,

maybe we can pull a little more, if you keep it well closed, pull well, ok go, here there is something

thing that goes up helps a little yes yes exactly helps to draw this I do not

know the name as they call it in English with angel hair angel hair yes angel hair

ok I put the last trucker in front because I have to pull up the bladder now I just have to

be careful that the patient enters in the mud a little etc. sometimes the bladder swells and

and this trocar sometimes ends up transversely, be careful, here I looked that it was well deflated

and now we start, he has a fairly deep pelvis, a Douglas

quite deep, keep it like that, thanks

he, he, he, eh yes, yes, yes

today only men unfortunately, they are not very swollen

in your opinion it is well released

in your opinion it is well released because they are not so swollen

if you can let me go a little more because I have little space we suck a little then the

simplest side is the rear one so everything you can do behind it is convenient to do it

because yes yes but it is really missing but it is blowing try to pull it up by 1.2 of pneumo that

if it is a little contracted we wait a moment that it does a little thank you here I had made a

a plane probably too far back I think this is more correct here here

sacred rectus ligament after which the rectus changes direction and becomes parallel

to the ground but now it is convenient that we lag a little in front because it is very

back in front then you do a little more so good here you pull a little here on the side it slides

slightly back with the little hand with this ok good so perfect and with the real sack ass

must come off with the piece in theory in the classic tm and therefore that part there must stay

with us and now we will soon have to see the vesicles arrive which are there maybe already yes

this one is a vesicle you push slightly more here on the side ok perfect is the tumor

is quite big, let's see a little how we are because I feel that I have little space to move until

I stay in this fabric I know to be in the right plane. Vest there, so at this

moment we are in front of the Denonvier, give me to suck a little. Ok I go a little from the other

now, let the grip go, ok we move from here, I have to coagulate a little, I feel

I'm getting into the area of ​​the very hard tumor bipolar down there ok come a little back

because she has to help me with this pulling a little up so to complete the round there a little more

wait that I engraved there so from here down it will be quite difficult we have to gain

a 7-8 cm. Here you can see well, come closer for a moment, here you can see well in front of the

vesicle and here the lucid of the novi, try to move a little over there, perfect, here we are

right on the tumor, so fantastic, let's see if you give me to breathe, you can feel right here there is a

very large tumor mass. This is a radiotherapy effect, however, it was then necessary to see the

histological if ... on the other hand this is the pre-sacral fascia, so if I go further down I get all ...

that is, I don't have to go, I end up in the pre-sacral veins that were bleeding, exactly, that were bleeding,

they were bleeding very often when we did, let's say, the tear with the hand, the surgery

pre-sacral band that in the pre-operative the tumor in some points invaded,

now with the radio it should be a little better, but this scar remains.

We suck and there is a lot of edema, this is sometimes a good sign.

Go with the electro, let's move for a moment to see what we can gain from the side,

like this, spatula, if then we can't go under we do from the bottom that point

with an anal astromusic, let's see, let's go from yours, let it go for a moment, like this, like this, down,

here you can see it again well here, the principle is to turn them around going to look every time

where there is this fabric and leaving the most difficult part for later, which is obviously the

left and rear side. Here there is a bipolar vessel. I have too much

inside, too much outside. Give me a moment the Enseal, something that bleeds behind.

too hard, I can't get it. Go with the spatula, suck in the middle that throws a little

here, ok, be careful not to go any further, prepare the spatula, let's make a change a little

fast that can make this thing jump here, wrong input, ok let's look a little

ahead, you have to pull like this, wait, ah it's here that it bleeds, it's torn here, bipolar hold

well let's lose a little we wash the optics thanks and then

very closed skin ok in front but we can go you give me the spatula

wait again that we also use her so from here we are almost under the

madness. Ok so good. Suck. You give me the spatula here. There we are right on the

pre-sacral band that is a bit ... come back for a moment that I have to find the hole.

We are in a little hole, damn it. I'm going to try to suck. Perfect. Yes this is the part that in

in fact with the T.A.T.M.E. we would have done it more easily from the bottom. Let's see if there is still a lot

look how beautiful, ok, give me, give me the Joanne, it seems to give up a little. Very well,

like this, let's wait a moment that I go away, ok, I was optimistic to talk about 6 cm because

because I'm afraid it's less. Ok, let it go, like this. Let's see a little how we are

put. No, wait a second to attack you, I'm trying to understand how to move.

Here we go well, go, suck and go with this. Of course you earn millimeter by millimeter.

Yes, on this side here it is a little softer, over there it is just sculpture, more than surgery.

but now we should almost be there ok try to give me the lenseel that we see a little if there

behind I can use it well here yes fantastic in theory it is also articulable but it is not particularly

useful here and here I would say that we have overcome the tumor rise and go ahead with that little hand

because it prevents me from in front I mean there good perfect perfect very well now arrived at this

level I can incite what I am doing now the denonv e exactly in order to bring myself

to the front here but you can still go down you give me the spatula that I have not

overcome the crevices here here the denonv e push it a little here that we go to see so

see a moment from here there we still have to go for example see then we do the

shows yes you give me the vacuum cleaner bipolar here maybe I'm under the tumor now give me the

seal yes yes maybe I'm under yes yes yes perfect we have arrived under the tumor ends here we have to

gain those two centimeters of margin also for the stem but behind I think it's okay

let's see a little, this pelvis is very narrow, as you can see it is a very limited pelvis, ok so

you give me to breathe, yes but here we are well below, ok go, now look I put, ah below,

but once you have two centimeters, here that there is my finger and there is no tumor there, the tumor

then starts a little higher we are preparing the last two centimeters three centimeters but

in reality it is said that once there is a clearance up to a centimeter it does not make a difference

it comes more or less but in practice here you end up going to the area where the measure ends

so I have to go a little further here in my opinion the right area begins to be seen

But the fact that it is flexible makes it less solid, because I need to make a solid movement.

Try to give me the bipolar.

And it turns a lot.

Yes, now I need to apply a rather intense force.

But here behind I still have to go, and the lens seal is fine.

No, it is very fast and effective on the E-mosta, there is no doubt about that.

But there is no way to fix it.

No, I don't think so.

There is the one without the joint, yes.

I think this joint is of little use ... if it damages you ... ok give me the crochet that we prepare

him too with a bit of edema, if you give me a batuffolo ... ok let's go with ... but maybe with ... no with the ligature

No, no, no, with this arrow here. Ok, now let's try to move to the central part.

Fantastic, like this. Ok, stop. Now let's turn slowly. You pull it straight like this.

Do you know that as a quality of the image you are among the best?

Noi siamo stabili. Grazie. Allora ringrazio Carmen e Aurelio. Sarà merito loro.

Ho dei soldi che il Dipartimento ha investito. Una delle due.

Tutti gli altri vanno a scatti e da un po' fastidi. Invece qui è una presentazione perfetta.

Grazie, Guido.

In addition to the excellent technique, even the eye wants its share.

Exactly.

Let's go there, to Enseal.

To see something that is all in shots.

Isn't it that some of them have the 3D and project it in 2D?

It could also be that, because ...

It could be, but there are many, perhaps too many.

This evening you ask Giorgio. We are in the last centimeter, we are slowly

coming here, it is healthy, I feel it very well, I have to prepare myself well in the rectum, then it will not be a

slap, then open those clamps that we have, that we use for ... here we have to clean ourselves a little

a little bit here in front, yes here it is still to be cleaned, go with the crochet, laterally we are there, I would like to

start again from the plan I had here, here it is, a little bit of blood that breaks, give me to breathe for a moment

because otherwise then the suturing does not close on top, it hurts with the clips and then loosens

then when you enter with the circular give me a batuffolo there is good there is something behind here this

here in my opinion it must be removed give me again this exact give me the lenseal that this is a

hold like this only even if there is still something behind here we can't breathe I feel good

to be under the tumor, the tumor ends here, I prepared below, I don't only have the

rear view if the colon is prepared behind, but maybe yes, maybe yes, try to give me the clamp

that we usually use, it doesn't open, it doesn't open, mount it well because that one, but that one

is a little better, in the meantime give me a joint, it's a nice wide one, but it's prepared, or not, down there it's

No, it looks like Cologne, doesn't it?

You stop there and try to put the finger that I feel if it is Cologne.

Yes, it is Cologne.

Go and see that we do the lap again for a moment.

Batuffolo.

No, yes, this if it works, yes.

Does it work?

Yes.

No, you always give it to me the same.

Give me ...

Guess Giovanni.

It looks right, just that it is very wide.

Even behind it looks good, doesn't it?

It looks all clean.

Yes.

Only that ...

No, you are pulling very badly, but don't give up now.

now it is in place only that the suturing is a little less performant than the other

maybe with the suturing we have it is better from top to bottom because it has a slightly limited joint

no no, this way they fit well

ok then let's open the suturing and see how we can place it

yes yes yes of course I would say I have to go in from here

in the majority of cases I enter from the left but here I know I have to enter from here. Do you have the stick to

change and open a disposable? I try to enter from the front. You are also one of the trockers and I have not seen you around, so this is an honor for you, we try to save.

now we are this suturing here is very good no green green is very good in the

part of the position of the clip and a little more inquisitive in the part of the rotation let's see a

little and it opens slightly less than the others let's see what we can do then let's change the

ok come on let's see a little try to give me let's get back well then pull this well

which one opened here next to it but it seems to me to have taken it now that I have not entered here

next to it has entered very well because it does not turn so much but it is very solid but it would seem

good but surely another please give me the little hand that we see what we have combined

No, but I put it from there for that, because it has an angle, that is, you have to lean on it to angle it,

so it is not so easy to angle it. Usually I put it to the left, but you have to angle it a lot, from here a little less,

that is, from here nothing. Now maybe we have to angle it a little so as not to end up ... Come on,

here it is, so you hold me, pushing a little forward, I should have been able to angle it a

now you have to try to pull it up, but not here, it goes too much in half, it is better that you remove the

angle, that you continue straight like this, I don't know if I go further, try to push it higher

hold it like this, give me your hand again, I don't know if they are over, maybe you can do this

job, no, on the contrary, you pull it towards you, very good, it doesn't want to go out anymore, it's because it's a

something left there, you have to give me ... the problem is that they are all 60 and then they hit and give me

another 60, the problem is that having only 60 the excess part is very long and I can't

hit it, the skin is so tight that I hit it and I can't go any further, let's see if I can,

You see, but maybe it's over.

You touched the piece, I saw.

Give me a Joan.

I have a pelvis that does not allow me to continue to hit the tip of the suture against the pelvis.

Here with a 45 we would have already solved the problem because there is little.

But there is not enough space there.

there it is said that the more loads you use the more you are at risk of fistula we hope it is not true in the

specific case it is because she then always goes in the same direction you cannot turn it you cannot make a

tube that emits this is a little bit now I try it only that it can be angled only by

leaning against it does not have an angle if not here so leaning maybe I

I succeeded, leave it to me too, now you Eleonora, push up, push up, push up,

push up, hold this, okay but there it's over, ok give me a scissors, ok go down too,

yes here it's over, ok mamma mia, hard, ok, okay then now let's make the cut to

pull it out, then you have to be very careful below, let's take a good look at this corner here

where I cut but I don't think we could maybe look then by injecting a little central give me to

suck yes check then by injecting a little that there was not an open angle that if not I put

a point here it was that angle there it is difficult to know if there is a column but it seems closed ok

well we pull out this beast we will need a fairly large cut take the reducer that

is a little bigger, the protector is a little bigger, in fact we did it but

with great effort, this was an indication of the TATME, I wanted to pass from above but

certainly from below the steel part would have been a little less difficult, let's pause

the insufflation please, let's try a little more because it doesn't come out from here, ok, give me two

a centimeter, not much more, but instead here it goes down well and the meso seems to me

also in the right plane. Then you have to see here the margin with the tumor but

otherwise it could not be done. Here if possible I usually do an

anastomosis on the side, but in such a narrow pelvis I will do a terminal

because we cannot then monitor the side. I need a Kelly. This is the

the artery with its lymph nodes and why don't you pull we go here so you hold me for a moment so

that goes up kelly scissors and here is the vein that as we said kelly ends up remaining

inside that lump and to be cut at the level of the artery a coil then if you have to

start going down simone really very very careful first with the finger we take a 28 29

we can hold it like this usually we do it in the meantime it comes down very well yes ok

It's because it's a kind of virtual pouch and it should have a better function.

And then the side is better vascularized in these delicate ones.

The only flaw is that you lose a bit of length, but it seems to me that you get there well.

Other times I do the plastic collar.

So, give me two ellipses.

How is this, excuse me, let me see, does it have a punch to puncture?

It has no form of punch?

Nothing, then let's do the terminal.

nothing I do the terminal because we have a sander that is not predisposed for that go

rastrello I do so then I cut from the other do not pull please if you pull it away you have explored

a little maybe rather they pull on the legs that allows you not to push too much on the perineum and

complacent ok we need a sander a little with a particular gadget to make the side and then

let's do the classic terminal here there is the piece go go go go go go go mario dueli yes

hello brother go give me a baton tell me it seemed to me that the side throw as you said

was even a little longer than the terminal part because there in the end with a point

to make a very small bag of tobacco, you put the tip in it and ...

Yes, yes, I usually use Duellis, those things that pierce, there are those tips with the tip, etc.

Yes, you're right, in fact, you could do it. In most cases I do it like this.

now I don't have my usual one and this will be even better in reality because it is supplied by Giorgio

so yes in fact I prefer to make some kind of pouch because the function but

now we have gone like this here but I agree with you, thank you, I have not cut these

these, sorry, sorry, let's cut the needles, ok, however it is very well vascularized,

scissors, cap, dirty, there are scissors in the hole and gloves, let go

of the one that is dirty, cap, we put the wound protector, the big one,

for those who see this huge thing here, but in reality then the tumor came out well,

you can start blowing, thank you, but even just air, I put a little water, as soon as

just a little bit of air, but just a little bit. Who is it that holds? Two Johan? Give a little

water for washing, even just a syringe here, apart from the fact that it is already there. Try also with your finger,

just go in with the optical, go in. It is very low. Yes, we are very low. I try to inject a

little bit of air. Give me some water. Since there was that doubt in that corner, come back with the

still? Go, wait, there's a bit of bubble. You go really slowly. Ok, nothing comes out.

All right, let's go, let's suck. We had a little doubt because we had given that

stroke of the scissors. Ok, so now you go inside, like this, and then you turn, like this. I stop there.

You see that we have made a slightly circular structure. Give me another Joann, another Joann.

But here it is not the usual linear structure, let's see a little how it comes in, let's see where we can get out of here.

Yes, I could also now maybe reduce this with a stapler, because it is here that I did not succeed, see?

I almost almost take this away with a stapler, do you have another load?

I almost take this away with a stapler, because I couldn't touch it, maybe it stays straighter, what do you think?

I would say yes, because otherwise you find yourself all over the place.

I still have an angle there.

It's not very easy to do something well done.

Probably with two tweezers. Give me another tweezers.

Hold that.

I don't know if it's a good idea, maybe I'll just remove this corner here or nothing.

that in any case it is closed well I do better I do worse no let's try well no it's straighter

come on okay give me a joan come in too much here perfect no no it's much better it's not

bad at all it has a nice shape perfect ok let me feel if you push a little more

more, very well, go ahead, push a little more, ok, go, perfect, go, go, go, go, ok, this is nothing, ok, no, it seems to me

much better than expected, turn up, as Armando Ancona said, you could

just do it on the side, but the defect is that you do not see much, but it was not

this pelvis was not so small, the tumor that was huge, point back,

let me see the sponge, wait, ok, bring it closer, here it is, you point towards the back,

very good, wait, ok, go Simone, close, ok, wait a moment, let's go back, let's see

if it is straight, ok, it goes down very well without traction, okay, go to the green, not too much because

that the fabric is a bit thick, stop like that for a moment, point towards the back that we just look

that they are not there, ok, let's wait a second, go shoot, shoot, give me a bit of bipolar up there,

this you do two laps then you come away, slowly, ok gone, then let's look at the rings, this one

is the one that eats them, I think, when it is a little higher, yes, here I am not sure I can do it, let's see a little,

the rings are excellent but still a test also on the medical-legal purpose let's see if it

does not go beyond, come back that I throw a little water from here, I still do an ostomy so

we are in 90% of the TMAs, we always do it at the base, then every now and then there is the case that we end up

not doing it and we often regret it, go ok, it is nice, it swells and holds, okay then let's do an

anastomia vieni pure via guardiamo se tutto apposta no no non peritonizzo vedi che è già

abbastanza intensa adesso è molto in trendelevo per cui quando tolgo il trendelevo non sarà più

in tensione però diciamo che conto sulla tensione per come peritoneizzazione vedi che qua ovviamente

da controllare bene che non ci siano ansie sotto ma direi di no quello è il colon ti cambi che ti

I'll let you do the stoma, if you want.

All right, I'll let Simone do the stoma now and take the opportunity to thank everyone,

in particular Guido, who has kept us company.

As far as I know, there is an intervention in Open and it goes off.

Evidently the technicians you have are exceptional.

there is no 3d this is true so thank you and thank you thanks to giorgio palazzini who

I will also thank directly by phone see you soon good evening to all bye