Prof. Sheng TAI Laparoscopic Right Hemihepatectomy

So, as we hear from the Harbin Medical University operating room, the patient is getting prepared

with disinfection and everything.

So, they'll start with the case introduction and presentation, and then Professor Tai and

the team will be performing the surgery after everything's done.

So, let's start with the case introduction.

好,我们现在可以介绍病例了。

好的,好的。

Hello, Professor. So my name is Lin Yu Jia from the Harvey Medical University Cancer Hospital. So right now I'm going to introduce this case for everybody.

So, this case, this is my patient, 6 years old.

The height is 174 centimeters.

Weight is 75 kilograms.

This 6-year-old man presents to our hospital with a liver lesion detected during a physical examination conducted 60 days ago.

So, no complaint of gastrointestinal disorders or other discomfortable symptoms.

So, he got a history of liver cirrhosis for eight years, and the patient, the HBS antigen

and HBC antibody is positive, and HB antigen and HB antibody is negative.

So, we can see he, we do the test like alpha-fetoprotein, larger than 1,200 grams per milliliter,

And we do the PVK2, 133 nanogram per milliliter.

And we do the PS score is grade 0.

And by the measurement of the liver test, we conclude the child's score is grade A.

And the liver function reserve, we also, sorry.

So we also do the liver functional reserve.

We can see the five-minute reserve is 44.9%, and 10 minutes is 20%, and 50 minutes is 9.1%.

It is okay.

I think we think it is susceptible for the large hepatic tectomy.

So right now, we can go through the contrast-enhanced MRI.

We can see the liver mass located in the segment 8.

And we do the score is LR5.

That's kind of 100% HCC.

And we can see that again.

Again, the tumor located very close to the, wait a second, the tumor very close to the right period left anterior and post-anterior, I don't think, this following.

Okay.

So, this is the CT scan, contrast CT scan.

It is the artery phase.

We can see from the left pictures, the tumor is enhanced in the artery phase and rapid

washout by the phase of the portal vein phase.

So our diagnosis is hepatocellular carcinoma, and the TNM is T2 and 0M0, and CLNC is 1A.

Actually, we know there's two different ways to do the classification.

One is Barcelona, and the other is if we use the classification, like a Chinese classification.

So, from what we understood, the Barcelona classification, a lot of cases based on the, say, the HCC is due to like the fatty liver or the alcoholic liver or some other things.

things. But for in China, the HPV is the main cause of the HCC. So we have our own classification.

And this patient, the tumor is larger. It's less than five centimeters, just one. And the PS is

is zero and class one, as you can see from here,

SPS is zero and class one.

There's no out-of-liver metastasis,

and we don't have the vessel invasion,

and the tumor number is one,

and the size is less than 1,000 centimeters.

Almost five, actually, from the CT scan,

is from the MI scan is close to the five centimeter, but it's still less than that.

So we conclude we have the 1A phase. So the surgical planning, we're going to do the

electroscopic right hemohabitatomy. If we found that if it is hard to do the surgery,

if it's hard for, I mean, we mean the liver left cannot maintain the functional of the liver,

So maybe we'll do the ALPPS, which we will perform the surgery, like maybe two or three weeks later.

This is our plan. Thank you. Thank you so much. Thank you for having us.

We're going to change the...

Thank you. Thank you very much for your presentation.

patient. And so we are waiting to receive the image from the OR now. Thanks a lot.

Oh, thank you so much. Thank you for having us. Now that we're going to do the surgery, right?

Surgeries. We're going to change the video to that part. Prepare. We are professor. It's not

here right now. We, other doctors in this group just preparing for the surgery. And

Okay, we can see from the left image, so we're just preparing for that.

Left observation, we will not insert our report, so sorry, just wait for a second.

thank you we now we see thank you and welcome in the congress of uh to hold the crew for the or

okay thank you thank you it is our honor to having us so it's a it is the first time for

our group to join this very great great conference uh and it is i i just i know there's a lot of like

other hospitals uh join in this congress like every year and this is a first year for us to

join this and we are so honored to be here thank you thank you for having us

Thank you to you. It's a great pleasure for us to host you here in Rome.

And why not in the near future probably. I would love to see you also here in Rome whenever we

are performing once again in presence in Congress now. Today it's only online.

Maybe if we have time so we can just go there to have a good communication with each other.

Thank you, Professor. Where am I?

Good morning, Professor, or good afternoon, Professor.

Good morning.

Start to do the operation, okay?

Great, thank you.

Okay, so they would like to adjust the signal a little bit. No worries. Just a moment, and the video will be back shortly.

It's surgery, and we have not decided as to if we can do the LPPS or we can do the right loop resection.

So we're going to use the atrio-hepatic glensin pedicle isolation.

So this is our approach. So right now, we just insert the port.

We choose the right side of the umbilical region, and this is our observation port.

We're going to insert our lens here.

So first we're going to observe what happened inside the abdomen, see if there's metastasis there.

The operating port for our right hand, we're going to insert the ultrasonic pinnacle.

and every

these two pores

the deposition

is a little bit higher

it's a fever

so in favor

of do the

do the

resection

the ultrasonic

is

Excuse me, Professor, are you between the legs of the patient or along the side?

The right side.

So our professor stands at the right side of the patient,

and the lens is in the middle of the patient.

and our assistant standing between the legs,

the two legs of the patient.

And right now we just dissect the,

we just point to the second hepatic.

This is the second part of the liver.

We were to expulsion the hepatic vein on the IVC

around on the coronary ligament has been dissected.

We need to be careful of the portal vein here.

There are no hepatic vein.

Oh, sorry, hepatic vein.

Yeah, hepatic vein.

This is the left triangle, the ligament.

But the reason not to opening also toward the left of the ligament is to a better mobilization

of the liver?

Yeah.

Okay.

Yeah.

What do you say here?

Vascular.

So the assistant, we just insert a port.

Okay, so now we will put the next two, right now we're going to insert the other two ports

for the assistant the one is to just enter the uh

yeah so the one is below that the other

can you see from the oh no we cannot see that

one is below the xiphod and the other is on the right uh mid coastal line okay thank you as soon

as you accepted the two extra ports can you show us from outside just to be sure thanks okay

This is too hard to hold the camera in one place.

Hot water, hot water.

Don't put it too deep.

It's easy to touch the camera.

You can look at the camera from this angle.

Can you look at the camera from this angle?

What?

You can look at the camera from this angle, right?

Yes.

Can you see this is the hole in the upside?

Okay.

Okay, thank you.

We continue to explore the the uh hepatic vein.

So right now the assistant do the operating operation.

So the assistant just decide to explore the the hepatic vein.

The right hepatic vein.

Is the patient in a reverse Trendelenburg position?

Yes, the head is elevated above the surface of the foot.

Head is slightly elevated.

Don't move. Don't be too full.

Move. Move. Move back.

Move faster.

Move back.

Come on. Give me the hammer.

We're now starting to process the first door.

Open it.

You still have one task.

You have to drag the drywall belt.

Hold it for me.

Yes.

Oh, my.

Today's left half pole is quite...

That left half pole is...

Li Jia, look at this pole.

There are a lot of small ones.

What is this called?

App size.

App size.

No.

Size.

And Professor Tai said

we need to pay attention to

hemostasis, stop the bleeding

手术就能稳定住,这个手术不要什么,就是不要每做一个操作,去找一次视野。

And Professor Tai said we need to fix the vision by stabilizing the camera.

谁能把控住手术的视野,谁就掌控了手术吗?

Have you a 0 degree laparoscopy or a 30 degree?

30 degree.

30 degree.

30 degree.

Yeah.

I need to get into the mirror.

You need to get into the mirror.

Otherwise, the surgery...

This is

vinyakiva, okay?

So for

clean

clean to resection

the liver line is in the

right line of the IVC.

So maybe we will reserve the mold, the caudal lobe.

So our approach is to, by the right side of the IVC,

so maybe we can just make more liver left.

Yeah, because the volume of the liver for this operation is just almost enough,

almost enough, sometimes not good enough.

So we need to decide the degree of the liver cirrhosis.

Even though we do the liver resistance test and the number I just present,

is almost abandoned but it's not that not abandoned it's just okay so we want

to when the left as more as a liver as we could

There are a lot of adhesions.

So we'll first start with the resection of the gallbladder and then we'll try to identify

by the first and second liver pedicle.

We ask for the CVP as low as we can.

So Professor Tai asked you lower the CVP.

Five is okay.

Around like five,

Otherwise, maybe it's a lot of bleeding or something.

The CVP is very important, very crucial during the surgery.

so they're sure they've assessed a neighbor you know he said I should get

on the wall time in the Italian your partner sir so what time is there in

Italy seven seven seven hours yes no no no the difference is the difference it's

Give me the camera.

I can't see the camera.

What's the reason?

I can see it clearly.

8.40 AM

Friday?

Is it Friday today in Italy?

Yes.

Very good.

I'm out of breath.

Now it's a focal length.

It's clear.

This is the effect.

We are dealing with the gallbladder

with a very clear vision here.

Yeah.

So you see the joists,

joists, biodex joists.

So the liver says it's not the simple size.

There's some like a biodex inside.

So it's complicated maybe.

Yeah.

Come in and help me.

Yeah.

Just go to the client.

Okay.

So, Dr. Professor Tai just said the assistant, the role for assistant is just use the two.

So, after operation, we easily, we must make the resection the tension.

To maintain the tension, the assistant used to...

you need to careful because here maybe we will meet the the renault artery or the renault

far area from the lens.

So it is-

So we need careful the diaphragm.

Diaphragm is very important.

Diaphragm may be the perforation.

If the ultrasound knife touch the diaphragm.

So here we need careful.

Careful.

Now, Professor Tai thinks that the dissection is well done, and since it's not an anterior approach, the dissection is very well done.

Now, they're dealing with the gallbladder, starting to deal with dissecting the gallbladder.

You see, this light is still going down, right, going down.

You look closely at that tumor, it grows in a very tangled position, a very tangled position.

The tumor located in the intersection between the right...

Here, the gallbladder artery, we can see artery.

Yeah, artery, arm lock, arm lock, green.

This is the small arm lock, gallbladder artery.

we're gonna do the approach,

like extrahepatic glansion, pedicle isolation.

蓝蓝呢,可能我们,我是要在这个粘膜下面扣锁,

but this we need to use the,什么,

蓝蓝膜,蓝蓝膜,

这就是做这个,他可能会觉得你为什么切得这么深,

因为我又是想用它去找这个干地。

So why we, the, the, let me say that.

So we were looking for the lennic capsule,

Congulation

So

Congulation

Bipolar

Bipolar

Bipolar

So you want to make the

Layer clean

lean so we just insert some some ceilings make the ballpattern ballpattern

congregation more effective okay it's the hands you know you were to go to

show you a show so the cheaper doesn't you know we are about to go to the car

not very clearly it's the uh

sagittal plane yes

Again, we're going to look for the right anterior hepatic pedicle.

So the reason why we don't remove the gallbladder yet,

because we can hold this gallbladder and looking for that.

For this patient, it's not that easy.

Sometimes when we find the Lewis...

How do you say the Lewis group?

Groove or sulcus?

Lewis group, yeah.

Not very clearly.

You need to remember the gallbladder.

Maybe I see the right portal branch.

Yeah, the portal.

Yeah.

Professor Tai said this could be the anterior branch.

Now, in the afternoon, they're adopting a classic extra-glycine sheath approach.

Do you think to do a selective clamping of right branch of artery and portal

to show the line of dissection, of the parenchymal dissection?

Turn around a little bit.

on the anterior posterior so we need to separate this one this one no here no here uh we we need

to do the isolation separately not yeah yeah not totally yeah the safety safety because we're

already we're already uh okay yeah so we're going to go to posterior posterior portion

so sometimes we need we we need a more fancy facility to the angel that the angle is not

That's good. We're gonna try to use our facility of our tools to do that

Sometimes the angle is very crucial here auto-wing. Okay

70 degree 90 degree

Right now we we have this a 90 degree degree one. So right now we change the observation port

哇,这个还可以。

Professor Tai used the observation port

and wanted to do the oscillation.

Again, it is the posterior paticle.

We want to do the oscillation separately.

哎,方向,方向。

分离起来,来。

回来,回去,不行。

分离起来,哦。

so everything will be smooth when we isolate the

so we don't have the

70 degree tools here so in some so we need a big one sometimes this steps is

is hard even I could 20 degree difference and make make a lot of

difference when we finish this stuff

We need to be very, very careful.

Very careful.

No, no, no, no, no, no.

Very well, very well.

Yeah, right behind you.

Come on, push. Push up.

Look at the bottom.

Push up.

Come in and let me see it clearly.

You have to move the joint.

It's missing one.

No, it needs a bigger one.

The bigger one.

Let me see.

Make it clear.

Let me see.

Okay, let me turn around.

Come here.

I'm trying to control the view inside.

I need to stabilize it now.

Go in, go in and see.

Let's try again.

I can't show it.

This is a must.

You have to place it right.

If not, I'll have to move it a little bit.

It's definitely not that deep.

Right?

Look at the end.

After you suck it, you have to go down.

Right.

Wait a minute.

It's very wide.

We just go into the parenchyma in order to explore the posterior pedicle, because we

tried several times, it's hard for us to dissect the pedicle, it's too wide, so we just go

into the parenchyma.

That's the front leg.

Don't look at the ground.

15 minutes.

Relax.

Get ready for two hours.

Get up.

Come in and look at the mirror.

It's very important.

If you can't get over it, I'll wait for you.

I can't see clearly.

This person's liver is much better than the morning one.

Relax at this time.

Relax.

I think there is some additional difficulties

from the hardness of the liver due to cirrhosis.

It's not very severe.

But if the normal, it's very easy to separate.

in western world maybe some kind of or easier and we don't know so

so for the current approach when we encounter difficulties in the right posterior

parts we will split the caudate lobe a little bit this is what we're doing now

This is also right.

Just put it there.

Right.

Lightly.

Slightly.

Right.

Slightly.

You can deal with all of this.

OK.

Spray water.

Or do it your way.

You see.

You try.

Don't spray water.

You're going to get wet.

Come in.

You'll get fogged up again.

You.

Follow me.

Come.

I'm still looking here.

There must be a gap.

Right.

After washing, press down.

Right.

You see.

I'm on my side.

I think I can get through.

This.

Push.

The ultrasonic scapel, we can use this for cutting and we can use it for dissection.

So every time we open the ultrasonic scapel, we're almost there.

Oh, I'm going to use this tool to dissect it again.

So maybe this time it will be there.

Again, right now, our observation port,

we changed the observation port to the other side.

So another time of vacation for 20 minutes.

This is taking time.

Okay, let's open it up. This gauze is very important. You have to push it up to this point.

Push it. Push it over.

Come on, the air is in.

It's thick here. Can't it come out from this angle?

Push it in. Push it in.

Right.

Look at the sharpest point.

Turn the direction when you look at it.

It's hard to come out. You see, it's a little straight.

什么原因,你看啊,这不在这儿吗,没问题啊,来,到底下。

Professor, is it dangerous to go the opposite way?

对策是不是危险?

Could you repeat your question?

I'm just wondering if it's...

Yeah, I can try, but...

Yes, he understands.

Okay, thank you, good idea.

换这手了。

没进,那个钳子没到位,到底下。

对,OK。

各位帮我,那个镜子轻点绕过。

不用动,轻微的在远离。

No, no, no.

进气吧,来。

别着急,别着急,别着急。

紧了肚子有点。

给我一点点药。

这个方向啊,direction。

吸开啊。

没事,慢慢往里推一点点就好。

这个都是微调。

Thank you, Professor.

转一下,我就能看着底下了。

转呢,我那边呢。

过去了。

过去了。

来,七号。

台上老师也说过,当从一个方向很困难的时候,

另一个方向一定很简单。

一个方向最难的地方,一定是另一个方向最容易的地方。

Translator? Okay. So, Professor Tai, okay, you please.

Okay, so Professor Tai also, just echo with Professor Grandy's

comment. When you encounter some difficulties in one direction,

the opposite direction should always be the easiest.

You need to open your eyes. Yeah, so thank you, Professor, for giving me the

good advice. We closed the

anterior and posterior, so maybe we will see the margin.

Ischemia region, because already blocking the two pedicle, so we are able to observe the ischemic region from the lens, so we're going to observe it later, after we do the legation.

Are you going to perform an ICG demonstration?

Yeah.

You still have to sign it.

Zhao Wei, it's very important.

You must sign it, or else I'll cut too much.

Yes, look.

We can see that the margin is very obvious, right?

The margin is very clear.

Yes, it's very obvious.

This means that the place where we cut should be more accurate.

meaning we have like it the right part of the vessel and ducts okay okay

Now we are about to start the anterior approach, liver splitting.

The liver parenchyma seems not so hard.

It is easy to dissect.

撕开了

又有静脉啊

不行这个我踩错了

看C-Hole

盯着我

不是盯着它不要让它没了

阻断了

照样还是往那边要掰过去

要掰过去

要不剩下的杆就不够了

或者这样

对这么一扯

这些都要给它整上要不这个气腹它控制不住的

Don't cut too much.

Oh, I'm cutting a double layer.

Oh, it's not a double layer.

Just a little bit.

Just a little bit.

Just a little bit of information in there.

Yes.

Just a little bit of water is enough.

Very good.

OK.

OK.

OK.

Yes, fix it.

Your lens doesn't adjust.

Now I need some details.

You always have to know what I'm cutting.

You see, the blade can't keep up with the top.

I'll follow it up.

If you don't push it, I'll cut too much.

So the attention is important.

The assistant has to pull the lever to the other side

to explore the regime so we can see clearly.

Otherwise, it's hard to control the...

这个没准是肝中啊。

Now we will find the middle hepatic vein.

Middle hepatic vein.

上头了,得给我扒过去才行啊。

然后得让我看着这些细节,轻轻的那个。

因为这个我可能是要多留一点静脉,

所以我不想把肝中静脉漏得太多,

直角。

So we're going to reserve more parenchyma,

so we are not able to to explore the mhv uh so uh so sorry translator so thoroughly or completely

忘了我们你很快乐

那我就忍了

你说有人快乐就行了

你管他是谁

就是

你这说的

那帮小子干啥去

就把你自己整来吧

干嘛去了

干嘛去啊

进进进

要放弃啊

哎呀

没钱咋整啊

啊

这个人有钱是有希望能活下来的

但是会太重了

进进进

这个人这么多小囊肿啊

是个障碍

他会

你别整交聚过整

你会有的时候分不清

到底是这个打漏

还是小囊肿的漏

So the liver cester is a barrier for us to do the dissection because sometimes it's hard to tell if it is only the cester or it contains some bile inside.

So we're going to use the Florence to see if it's a complete resection.

Because we inject the ICG before.

Oh, ICG, I want to take a look, see if there's any...

Wow, sorry, not very clear.

If this doesn't work later, I might need to check the sound.

I'm going to look for the standard USB card, so I can see if there's any leak.

When did you inject the ICG?

What time? I'm asking you, when did you inject the ICG?

Tuesday.

It's three days before.

It is before. Maybe it's a little bit short.

Maybe the cirrhosis or the ICG excretion is kind of slow due to the cirrhosis of the patient.

Maybe.

Yes, that's good.

Since the second wrinkle maneuver, we'll start with 20 minutes.

It's each time for clamping.

So we're going to maintain our direction all the way to the dried hepatic vein.

So Professor Grandi or other professors from Italy,

do you have any suggestion for now? Because as we saw, we have encountered some hematoma that

contains bile juice in it, probably some bile ducts. And also from the ICG, we don't see clear

signs of which part is tumor and which part is the normal liver. Do you spot the bile leakage?

Do you spot it?

So for the biojuice leakage, they are from the hematoma, we talked before, within the liver parenchyma.

So when we transect the liver parenchyma...

So it's very hard to differentiate which part is the hematoma, which part is the bioleakage.

So it's also difficult to differentiate the origin of the bioleak.

Because within the hematoma, you can see yellow color, which resembles the biojuice.

So we don't know whether it is biojuice.

Do you not think that this difficult to differentiate the ISG inside the hematoma or biloma is due to the time of injecting of ISG?

Yes, probably.

Probably it's due to the timing of the ICG injection.

Okay, let's send the group.

Now it's 20 minutes.

so we will have the five minutes to have a rest okay d clamp for five minutes

probably i'll consider ligating two of the liver pedicles

Now we'll find the right hepatic vessels, and then I believe that's almost done.

So right now we're going to go along the IVC.

Now that it's vacation, maybe it's just a short.

Here's some bleeding from the short hepatic veins.

We need to compress it with the gauze and deal with it later after clamping.

We need to expose the IVC better by rotate a little bit, but for the short hepatic veins, it's no big deal. Don't worry about it too much.

Okay, we'll start clamping.

Professor Tai is teaching the assistant

and how to adjust the camera.

来,对,使劲往那边扒这些东西,对,扒这些东西,对,我来看看下枪在哪里,安全,这不下枪吗?

So we've tried to figure out where IVC is.

Yeah, we were formed the IVC,这个肾上腺.

Adrenal gland?

Yeah, maybe.

等会儿,你看,我现在后手抬起来,我的方向是下枪,我要看到下枪。

赵伟,就拿钳子吧,这点杆,我扒走,拿钳子,对。

And we'll transect the liver parenchyma.

We're providing some temporary bleeding control there.

And then we'll go with the Rancomo transaction.

The possibility that the fluid coming from the cyst might be ICG

might because due to limited time after injection.

Well, first compress it with the gauze.

Okay, now we'll lighten the liver pedicle so that our surgical vision should be much clearer.

So SG is very crucial when we do the dissection, it can give us the way, otherwise we're going

We're going to go all the way to the other side.

So we have to cut this off.

And we can have the better sight.

We need some tension to expose the tumor better

and we are approaching it close to the IBC.

To completely resect the tumor, we must dissect close to the IVC.

我得去盯住它。

我要松一下阻断,压一会儿,压一会儿,不要管它。

来,我扯,马上往上扯,跟上这镜子。

So we will declamp for some time.

Yeah,不要着急,压上。

有耐心压上20分钟,啥也不出了。

And we need to be patient, compress it with the gauze for some time,

maybe 20 minutes to stop the bleeding.

换一根,没压住,压一定要压好。

再来块纱布。

It's too short, so it's easy to fall off.

A little longer.

Okay, okay.

A little longer.

What if I hit my hand?

Oh, it's not your hand.

What are you afraid of?

Oh, my gosh.

No.

No.

If you do this, this finger will be short of blood.

Keep pressing it.

Press it for a while.

Press it for a while.

You can make it clear.

Our 2-D machine doesn't press hands.

It's not short of blood.

Yes.

Really.

Thank you.

It's the best timing for hemostasis.

Now we start clamping.

So, Professor Tai said we have already done with the anterior and posterior liver pedicle dissection.

Now, we are going to do the caudate process to have a better vision of the IVC.

Look at the light. I look at the flow.

This is a tumor.

Why?

We will move the resection to the left.

Okay.

Come in.

If the blood pressure is low, remove the blood.

Okay, let's wipe it off.

This is where the blood comes out.

I can't see it here. The back of my hand is high.

Look down.

Just pull it over.

Don't be afraid.

Move it a little bit to the front.

To here.

Come in here.

Don't worry about the lower part.

I feel like there's a small artery there.

Let me do it.

We need to make

sure that we don't touch the tumor, we need to dissect around the tumor to keep it intact.

Let me check the position of the stream.

I need to check the light.

The stream is now on the bottom of the lower wall.

Is there any back and sides?

I don't see any.

I saw the 3D version, but I didn't see the back and sides.

But that one is very wide.

I'm looking at it now.

The stream is still a long way from the lower wall.

No problem.

No problem. Can you hold it?

Hold it. It's okay.

哦来这个下墙不太好处理他出不来没发现吗

这时候必须得扒个我现在流子已经来往后撤

这个镜子是有点误招招就感觉这个这个镜头我怀疑是不是这块没擦干净啊

啊擦不擦那块

你看他有层膜

先处理处理这儿不要着急

动开

动开的没事

没问题还是把扒地干地着

然后要转过来给我看

哦信息写好写好

Wait, wait, wait.

If it's dry, you don't have to worry about it.

Move your finger.

Move it a little bit.

Have you ever tried to find a small gun that has a eagle mouth?

Move it a little bit.

Can you make a gun sound with 45?

45.

Control it well.

Actually, it's okay if I draw a line.

I'm going to tear these things down.

Don't tear it.

I'm going to pull it out after I go down.

And then I'm going to take it out.

镜子,现在就是要你的镜子。

哇,近一点镜子,干啥呢?

赵立强。

Should we remove the clips, professor?

Oh, yeah.

We need to remove...

Remove all the clips.

我现在...

那谁啊?我现在需要你这个镜子往里进,

你不要一动不动的在这儿,好不好?

We're gonna remove the clips first.

我这边多少双屏,我看不见。

文科系大叔。

This is the right inferior posterior hepatic vein, very wide.

So bleeding was also very significant.

Good maneuver, Professor. Not an easy one, definitely.

I-R-H-V

He said the operation is very good

It's really not easy

Sorry

I need to relax

That's to help me

You see, you press it down

OK

It's so hard

Let's see if I can get the intestines out

Take a rest

Have a rest

You deserve it, professor

OK, have a rest

Five minutes

You can see I'm pushing it.

You still have to look at this.

It's really unclear.

That's it. Don't move.

Don't move.

No, how is this?

Is it not enough?

Or where is it?

Why?

Come on, I'll see.

Here, come on.

I see the gun.

I'll still push a little bit.

The gun.

I just cut the gun a little bit.

It's pretty far.

Yeah, you can cut this part.

这就是下墙,我必须紧贴着下墙去做,否则就完蛋了。

Now we are dissecting very close to the IVC, and also close to the adrenal gland.

来,指甲,因为只有下墙是我的标志。

The IVC can work as a landmark for dissecting.

底下来轻轻吸一下,然后我能看清,吸吧拿走,推一下,推,没事。

And now we are dissecting all the way to the right hepatic vein and split the caudal lobe.

这是来现在呃刘子我们基本把它包过去了啊来吹一点吹一点啊来纱布有吗这里面现在洗洗洗里面有一块吗大的那块纱布在这来我要看看上头来这个小的先给我啊放在这个位置啊标志OK来看上头这还要把这个要不是很难看的哦对来用杆用这个杠杆的力量哦对这个力量

So, Professor Tai said we need to aim for the IVC recess.

Otherwise, we cannot reach the root of the right hepatitis B.

Let's push this one over there.

Yes, this one.

I'll push this one over here.

Go in and take a look.

Be good.

Take a look.

Take a look at the money.

Slow down.

Slow down.

Wait a minute.

If we don't take this,

we will lose the money.

This action has been

until I cut off the bottom of the wall.

Don't come out.

Don't come out.

看不清啊

进来以后

等我要用的时候

你就没了

别动

这会儿快到干诱了

你看我怀疑

这是可能

有可能别就是

干诱的分支了

后手抬起来

看看能不能整清楚点

来

海驴下墙

进进

不是为什么

它有点夹不住了

快点快点快点

是不是阻断呢

快快快

快进吧

快阻断吧

以后一会儿你再整

没事快进

快进快进快进

进不了

Ah, which one has grown?

Oh, right.

Dig it over.

Oh, okay.

Spray water.

Oh, good.

Yes, spray water.

Go into the mirror.

Stereo.

You have to do three things.

Every action has to be done like this.

Look at this stereos.

Yes, put the camera there.

Don't run away.

Come on.

Green.

Wipe it faster.

The time is up for you to wipe the mirror.

Every time, it's back and forth.

No, so we have encountered some issues with the cameras.

Not very clearly, okay, I don't know.

继续做一做,继续做一做,没什么太多东西了,我撑起来,我要给它拖起来啊,对,你看,其实马上这个肿瘤就快下来了,对,把这个视野给我视角,

We're trying to expose the IVC and dissect along the IVC.

Since this patient had a very thick right inferior posterior hepatic vein,

so the right hepatic vein should be very thin yeah maybe maybe i'm not sure

It looks like the adrenal gland is adhesion with the liver.

now we'll start clamping hopefully it's our last clamping yeah maybe i hope so

Okay, so a question for Italian professors.

For such cases, would you do robotic hepatectomy for such cases in Italy?

Robotic-assisted laparoscopy?

Yeah, the ones that are addicted to the liver surgery

surely can take advantage of a robot, yeah, definitely.

This is the resection line.

Yeah.

So I cut it a little over there.

Over there, it will become six or seven sections.

So at this time, you will find that your tree's window has become larger.

Come on, cut it.

Come on, cut it.

I just let you follow this.

Open this part for me.

Come on, get into the mirror.

Yes, turn it around.

This part of the oil is still only in your place.

Can I see it?

Come on, let me go back.

Oh, don't.

When you come back, don't make a mess.

这是我正常标准的右半杆的终点线,是坐到这儿,是这个位置。

This is the standard midline of the right hemiphthectomy.

Here is the girl,来我车,所以现在我是多留了一点点的杆,

我要尽量找来,别动了,我顺势劈过来啊。

We preserved a little bit more of the liver and parenchyma.

转一点,我都就在这儿等你呢,你这咋说也不行啊,你这就是不动了。

Sometimes the liver cysts also looks like the veins.

It is somehow confusing.

Next clip.

Okay.

I agree.

When you are in doubt,

the next clip isn't a big deal.

它说我们这个夹子的处理,它做得很好,它是同意你的做法。

什么夹子,就是,你看你的墙呢。

You mean, when they're removing the clips, you agree with what he's done?

No, I told you, when you're in doubt what it is, is it a kiss, or is it a vein?

And hemlock is not a big problem.

An extra hemlock, just like this.

Professor Tai assumed that this is the right hepatic vein and he would like to try the lock on that.

咱们有可能管道都处理完了

你看我要周起来它

吸干净

好来处理肾上腺

对往那边扒还是

冲水

冲水往里进镜子

太远了

又远又没有焦距

你这镜子给我

掉了命了

转一下往那边

往那边转这个就好办了

肾上腺

肾上腺一会儿再止吧

Now we can see the tumor on ICG, and now we are dissecting close surrounding it, and I think this is the last part.

This is the gallbladder.

This is the most important.

I'll push.

You're loose.

Oh, yeah.

Look.

Help me.

I can definitely see it.

It's coming over a few times.

This is a man fighting.

You two don't help me.

Come on, help me.

You two, Zhao, do this.

Come in and find him.

Find his money.

Yes.

Can you come over?

Yes.

Okay.

You can definitely come over.

I can do it with a little power.

Don't move.

Move back a little.

Move back a little.

Yes.

Mirror.

You see, I can see it.

You're trying to force me again.

Find the direction.

You see, isn't that good?

So we meet the seventh branch of the right hepatic vein.

Yeah.

This is some of the problem of me.

No, I really don't think it was a problem of yours.

This is not an ideal case.

I mean, it was difficult.

It has been difficult.

And these are the last bites.

Come on, Qiong.

He just commented that it's not the director's problem.

It's indeed the patient's problem.

His解剖结构也是比较复杂的。

本来就是一个比较困难的一个病例。

好好测测啊,Thank you.

这有点难,因为有些血液,因为有点雨。

来,谁帮我拧一下,来。

因为出血,还有皮鳞这个肾上腺都带来了一些手术上的困难。

看看有没有,看看有没有夹,你看,等会儿啊,就是往那边,别被我碰掉了,很吓人啊。

OK, maybe the last one,别扣,别扣。

It has been tough, professor. It has been really not an easy one.

It is indeed a very complicated case.

Maybe we will...

Tell him if we have that...

Do we have a 3D reconstruction?

Yes.

Can we take that picture out and have a look?

So I believe we can have a look at the 3D reconstruction.

Yes, 3D will check the IRHV and...

我想看一下我的那个red hepatic vein,

because we cut the three branches.

So I want to check the problem.

You see the red hepatic vein, very slim.

哎呀,今天这个镜子不知道是哪块的问题啊,

那个谁呢,跑哪去了他。

你看这个镜子有问题,

不是清晰度,

we need to pay attention whether there are some clips that has dropped

we need to check these clips do you usually apply some

hemostatic gel or something else on the yeah yeah yeah sure i will use some the

for the bleeding but i think it's not the important thing

Now it's hemostasis around the adrenal gland.

麻醉师现在你可以补一页啊

不限制了

你可以快速的给他500

然后我这边呢

来好

拍照双击撤

等会儿别揪了

你看没气了

你等一会儿

再直直写咱们就完事了啊

想想还有啥需要处理的

胆囊千万不要给我忘了啊

谁啥时候把胆囊过来

那谁

那回是谁把胆囊过来扔了

这边身上先不管了

杆上再看看

否则我们说就是咱其实留了一点点的八段

标准的右半杆就是要把下腔这个B全露出来

In this case, in order to preserve more liver parenchyma

We preserved a little bit of segment 8

Before operation, the volume just 37%

So I reserved a little, maybe the segment 8

eight here maybe yes we see we have the the size of the tumor was seems to be bigger and more to the

left that we appreciated in the preoperative image

The cutted lobe is a bit ischemic.

We see the color of the liver is good.

So now the ischemia.

So second way to check.

Yes, it is.

And the way.

Okay, finish.

I think you need a good neck-and-shoulder massage.

What does that mean?

I don't understand.

What's the meaning?

It's probably the control of the lens and the space for lifting.

What?

The control of the lens and the space for lifting.

He's talking about you.

Sorry, I'm not.

Let me correct him.

He's probably saying that after we're done, we should massage and relax.

Okay.

Massage.

Sure.

Professor, I would like to ask you a question.

Okay.

It's an easy one.

Just take it as a cooling down period.

I'm always astonished about your numbers.

I mean, the Chinese numbers of the surgeons.

So, how many surgical procedures on the liver, I mean resection, and I don't know if in your department there is also a program of liver transplantation.

Anyway, how many liver resections do you perform per year, I mean your department?

transplantation one year anyway 300 or 400 liver resection and how many surgeons are skinny we have

15. uh this is just the liver we're including the some you know the pancreas or the pd ripple

sometimes cholangiocarcinoma some the the daffinci the the resection so one year totally

the 1500 totally including the the liver pancreas and a bio doc but in this hospital because this

is the the tumor the cancer hospital so we don't have license to do the liver transplantation but

in the second affiliated hospital we do liver transplantation every year nearly 10 cases okay

Okay, thank you.

I know in the Italian,

in Italian you do the auxilliary liver transplantation.

I know.

Yu Jia, what did you say?

Auxiliary liver transplantation, right?

Yes, it should be.

Auxiliary liver transplantation, you said?

Yes, auxiliary liver transplantation.

I know an Italian professor, very famous in the world.

I learned this technique from his paper.

Okay.

His name is Riley.

Maybe. An Indian professor, but working in the Italian.

Okay. As a youngster, I used to be in the Living Transplantation Program in Bologna with Professor Gazzetti.

Now I work in Ravenna. It's a small city and a small hospital in the northern part of Italy, and every year it's...

Are you from India?

No, no, not really.

I'm from Ravenna.

Rovenna is in the northern part.

Rovenna, Romania.

Yes, right.

You know that place, mosaics and so on.

I know, but I don't have a chance to there.

Well, it would be a great honor if you succeed in getting in Rome

for a congress of Giorgio Palazzini.

You should take the chance to visit also.

I mean, it's a very old city.

Maybe we will give the drainage.

Wait a minute. Don't move back.

I'll push it over.

A big one.

We have to look...

Just keep here. It's difficult to move.

I want to look inside.

There's no blood.

It's very clear.

We need to push it up.

This is very important.

It's the last step.

Let's see if there's any blood.

The greater momentum can be used to fill the space on the right side

and it can also be a good tool to stop the bleeding there.

So, Professor Tai is asking the colleagues from Italy,

do you have any suggestions or comments for the whole surgery?

Thanks for your attention.

Not any suggestions, only compliments for your...

其实是没有其他的意见了,还是主要是想要称赞您,祝贺您这个手术取得成功。

Thank you, sir.

So, really, no suggestion.

We are so pleased and so honored to stay with you today.

Yeah, thank you.

We just want to thank you.

I hope we have the next chance to do this, okay?

Hopefully.

yes definitely yeah how are you accepting the specimen professor how do you take out to the

the specimen oh i will the uh in the middle to uh h hcm the resection the the incision

Thank you to all your crew.

Thank you.

Thank you.

Thank you, sir.

Thank you very much.

Thank you.

thank you very much for your demonstration

yeah if you have chance

I hope you can have chance to

to China for conference

or for some

lecture okay

we would love to

maybe

okay

ciao ciao

see you

okay thank you

see you next time