H. VAN DERWALT

Can you hear us?

Yes.

You have told me, I'll say.

I'll say.

Right, can you hear me, Peter?

Yes, yes.

Welcome back.

Good.

Thank you very much.

Right.

Can you tell us exactly the position and the position of the trochers and the intercostal spaces, of course?

Right.

What we have here is the patient is lying on his stomach.

So he's prone now.

And this is the scapula.

that's the spine there, the head of the patient is there, the feet

is on that side. This is the tip of the scapula

and this is usually our reference mark, that'll be

11, 10, 9, 8

so we'll put our camera in the 6th or 7th intercostal space

I think in this case it's probably going to, because it's quite posterior, so we'll probably

go to 6, 7, 6 and then one rib

below and rub one rib above we put in our throw cards for the for the for the instruments right

so let me see there's my scapula also right I think I'm gonna do it like that that'll be fine

yeah so so right here we go for my disconnect here now what we do is when

we go in we disconnect the we disconnect the lungs so that they can actually go

through the blunt trocar or actually the open trocar is the pressure is now set

to eight millimeters for this case right this one's about let's see if we're dancing

right here can couple let's do it yeah couple nature okay deeper right on couple here okay

now we're going to go in with our camera port it's going to put on the co2 there

good there we are are we on the inside picture now

Good. You had us on the outside pitch, eh?

Yes, we have a pitcher and a pitcher right now.

Yeah, you can...

and that's the port that we use to the lung out of the way it's Ozzy goes what

space are you on now what the line is it well the one at the top that will be

about the fourth fifth fifth intercostal space okay one of us be up see fat come

see grandma one of us in open companies and I think that'll be fine that'll be

fine. Right now I go one rib above and one rib below with my two other ports. This will

the lung here. Right down to there. What's going to be the landmark on this horse up

up to the azygos vein?

Well, what we do is, look, you're at least 5 to 7 centimeters proximal.

We're probably going to do anastomosis around this area.

We'll have a look now.

But we dissect the esophagus open to the azygos vein in this case.

So there we have it.

Okay.

A little bit back here.

A little bit back here.

Let's just make sure.

That's over there.

That's over there.

Is that the tumor already that we can see, isn't it?

I think that's the esophagus.

No, no, below, below, just below where you touched.

Now, I think the tumor is still lying inside the abdomen.

All right.

Yeah, the tumor is still lying inside the abdomen.

The vagus over there.

Okay.

There you can see the vagus.

Yes, very clear.

Actually, I think this is quite a low cancer, so that's more than high enough.

Okay.

Come back a bit.

Another.

This is the right vagus that you are holding, isn't it?

This is the right vagus, isn't it?

Yeah, yeah. There you can see the...

Okay, so we are actually quite high up on the esophagus,

because there is three centimeters, there is six centimeters.

meters. Yeah, it's not going to go that way. Yeah, yeah, it is so. Right, yeah. Okay, right.

Look at the bottom. It's right, isn't it? It's right, isn't it? No, no, it's completely

because this is all esophagus from there

this is still esophagus

to about there

the dissection is excellent

just to carry on

step by step

because there are also

young surgeons

surgeons and I think in the auditorium should be over 1,500 surgeon besides

other 30,000 connected on streaming or watching you at the although there are

some 15 screens going all together with different surgical theaters both in

Italy all over from South to North and Europe yes it was also linked to Moscow

imaging good right so I think we've now dissected and loosened the esophagus we

had a little bleeder on the esophagus there that's been taken care of so have

a nice clean surgical field now what we're going to do is to divide the

esophagus these are little esophageal veins I think that are bleeding

minimally I beg your pardon I think there are little esophageal

bleeding bleeding yeah yeah it was there but that's uh yeah that was the little artery over

there we've taken care of it so that's fine right okay everyone let's use it as also stomach dune

i think from there it might be the easiest like that angled now from here we can angle it like

that to that okay so we're going to use the left port for the 12. maybe two i'm not sure

okay give me the blue stapler let's just check where our angle is i think the nasogastic is

pulled back well enough here what i'm going to do is just to angle the staple now that's it like

like that, a little bit more, that's maximum angle.

There we are, all right, let's see, is it here?

Come up, just, all right, .

That was fair enough, yeah.

Of course, you must make sure that the nasogastric tube

is pulled back properly, otherwise you end up with,

yeah, sure, dividing that as well.

Yes, you have insisted with the knees to pull up.

Yeah, I had him pull it back just now.

Let's just have a look.

Oh, he stapled through?

Yeah, he stapled through.

And you need to visualize also the thoracic duct.

The thoracic duct usually lies at the back here.

I'll try and show it to you.

Where's my other grasp?

Do you have another grasp?

Come a little further.

I don't think we'll see it here

because it's still under the the uh behind the uh the player there yeah we won't see it yeah it's a

bit our angles forward it's too deep yeah yeah right now we're gonna pull that stomach through

and this is now going to be trying and testing because that's a very large tumor that we have

I'm just going to throw this over at the top there.

That's it.

What is the landmark to stop pulling the stomach through the chest?

You have to feel.

Normally what I try and do is, that's the joint of my first and second staple line.

So the last staple line is over there.

So I try and leave the antrum in the abdomen and just pull through the staples.

If you start seeing the anthem or the end of your staple line,

I think you've got too much tension and you've pulled too much.

Right.

And you can actually see that.

I beg your pardon?

Nothing.

Carry on.

Okay.

Right.

Now what's nice, if you see a bit of bleeding over there,

you can see that's quite bluish over there.

If you compare that color, this is quite nice and pink.

So we will now divide the stomach around about there.

That will give us more than enough length.

I want to point out that it is not necessary to caucarize the duodenum at all.

That's right. Not with the ovulus is not necessary.

I use a blue again. I angle the staple a bit.

Otherwise the vascularity is fine.

I see there is a blue.

I think that's enough.

Now we're just going to divide that just give me the scissors

Okay, I'm going to have to use your thing over here.

Assistant, hold it like that.

Go.

Come on.

Wait a minute.

We went through over there, eh?

Yeah.

We got to there.

Brandt, it's a bit key.

Any possibility to twist the stomach at this stage?

To twist?

Yes.

The important thing is you must keep the staple line towards yourself.

Come back with the camera.

what if that is lying towards you it's you probably won't twist it okay come

good stood for see now so has he's a base we get off the measure and check

where we're going to do I think it's tell up a camera about the that should

should be fine a semi-sum right hey Brant to me can you be on it okay

can I say water come to Merck you let me see me a nice silly camera

okay let's stop name it still low the camera come

Come back.

Come up.

We can't do this.

No.

You don't have to move that thing.

It doesn't work.

You're not...

No.

And it's straight.

Are you through the stomach?

I'm through the stomach.

I'm inside.

Hold the camera.

I just want to get rid of a bit of smoke here.

Let's just deflate a bit so you can see better.

Right.

Alright, now I'm going to ask the anesthetist to push down the nasogastric tube.

Grasper, grasper.

Tankies eindelijk voor mij hier, hoor.

Push it.

Push, push, push.

Push slowly, slowly.

Push, push, slowly.

Is hij fout?

Hij komt.

Ha?

Draai de camera.

Alright, push.

Wait, back a bit.

Trek terug, trek terug.

Trek terug.

Alright, push again.

Push.

The incision of the esophagotomy should be above the stapled line, isn't it?

The esophagotomy is going to be above the stapled line.

Yes, that's right.

Yeah, but for me, it feels terrible.

That's the mucosa.

Yeah, I could see it.

Okay, I'm looking for a thin thing.

Let's just clean the lens.

Do you have a mirror in it or something?

No, so we're going to grab his face.

Okay, that's fine.

Let's just take this one.

There we are.

All right.

Have you cleaned it, Mickey?

Smaller than this one.

All right, we just want to check.

Cream, yeah.

Come now there.

Make sure that we are on the inside.

There we are, yeah.

We actually did this.

On the top of the tip of the energy tube.

Yeah.

If it's nice, you can press down the energy tube

and it actually makes a sort of an indent,

but I didn't want to do it today.

Right, there's the nasal gastric tube.

It went into the corner.

Pull it back a bit.

Stop.

That's it.

There we are.

So we just, you must make sure that you're inside the esophagus lumen because you can very easily make a layer between the muscles.

Right.

Okay.

Now I want you to pull back that nasogastric tube quite a bit, quite a bit, quite, bring it, take it back, back, back, back, back, all right.

Fine.

Right.

Now we're going to do our anastomosis and I'm going to, again, tilt my stapler.

I'm going to start by putting in the lower jaw at the bottom.

there it's in i'm getting feedback there right yes you must have it exactly right

uh push down that nasogastric tube again stefan i could tell you full on

just push it down again wait wait wait wait back but back right next to it

yeah okay just hold that i just want to give me this one where's the nasogastric

the tube, push it down, I can't see it, wait, stop, there it is, back a bit, back a bit,

keep it in, like that, okay, this is another way to do it, hold it, this is another way

to do it, to make sure that you get into your right lumen, it goes in there, it comes up

here, right, that one comes there, right, now I'm sure I'm inside the lumen of the

the esophagus because that's quite important you can very easily get a false false area and this

nasogastric tube helps for that to where i think that's enough

that's fine good so now we just have to close up in this way with the nasogastric tube

tube, because those blind, maybe you can also go to a false track.

Yes, that's the big problem with this, is that false track.

Right, now I want the suture, and the

Fogbladbeck, so that you don't touch it.

That's it. All that, one like that.

I want a grasper first, please, bring me two graspers.

Let's have a look inside, just make sure everything is fine, there is a mucosa, so we have to

take deep bites, there is the anastomosis, right fine, there we are, right.

What suture do you use?

I use Vicryl, only Vicryl.

I used to use PDS, but you know with the laparoscopic work, the PDS can actually be very difficult,

so I've stopped doing that.

huh well okay okay now like you didn't get killed there i just want to set my camera a bit

there we are i think if it's like that that's going to be fine

pulled into the into the port

yeah okay just want to take this out of the way deep bites in the esophagus yeah it's

right must make sure that you have the mucosa of the esophagus in the bite

it's nice if it bleeds like this because then you know you've got a good blood supply of your stump

yeah the beasts are very vital we can see well

Sorry.

It's like a studio clamp.

Turn the camera to the other side.

I'm going to have to...

If you have the time, you can go.

Okay, sorry.

See?

No, actually, I can come later.

And the assistant was his sister, and she was pregnant as well.

What is this trio of vikra? Is it going to be the second layer?

No, one layer only, and it's two of vikra.

That was nice with the distance.

See you tomorrow.

Turn the camera right again.

Very well synchronized also with your assistant.

I do the, yeah, I am. They're good.

So we are going to use another suture as well for the final suture, I think.

And then we can knot them there because I think we, it's the suture.

Buongiorno a tutti. Benvenuti a Roma.

also this year we managed to set up this congress it is

more and more difficult we are 30 years from the first edition the first edition

was made in 1985 also then in November we repeated in November this

congress you have seen that there is also a big Chinese surgeon came to

find us here in the classroom together with his collaborators and he made us the

the request next year to be able to have a direct connection with his country so

we will return to do as it was done previously in the past years

some more connection with foreign countries and therefore thanks to all thanks

always to the sponsors who have contributed to this event but also

thanks to all those people we can go back all those

quelle persone che si sono collegate su internet vedete che ieri si sono

collegate 5.172 persone 4.500 dall'italia e i paesi collegati in tutto

il mondo sono stati 33 quindi è una cosa importante questa qui la diffusione di

internet la possibilità di seguire direttamente da casa gli interventi

senza spostarsi anche se è senz'altro più piacevole venire a roma no è la

la nostra capitale, una città che merita e merita specialmente dopo il congresso poter

frequentare Roma Centro.

Vi ringrazio a tutti e prossim'anno, lo facciamo o non lo facciamo, lascia a voi la decisione.

C'è la possibilità di votare con i quiz, fate voi quello che tenete più opportuno.

Grazie a tutti per essere venuti anche quest'anno.

We are good for here.

Right.

Hi, Ian.

I'm back.

I never lost your connection,

but we're busy listening to Professor Palazzini,

which was saying, besides thanking everybody,

including you, of course,

and giving us some figures.

Apparently, there are 2,000 surgeons in the auditorium

and connected via internet over 5,000,

And besides, 4,000 in Italy and the rest all over the world with 33 different countries.

And apparently in the editorial there is also one Chinese surgeon which was basically astonished about the Congress.

And they asked for the next year for first time to be linked to do a live surgery from China next year.

so it is a fantastic billy billy and this is the 30th edition and the first one was done

was performed in november again in 1985 right that's actually wonderful uh we can just show

you this is just the i think a blood vessel over there right that's clotted up the other anastomosis

we start on this side and we're moving over to that side this was not up right there we are

So there's our anastomosis between the stomach and the esophagus.

Nice wide anastomosis, one layer only.

We've got the nasogastric tube in for decompression.

And now we're just going to put in an underwater drainage tube,

and that's the end of this operation.

And of course we have to take out the stomach.

That's the most important.

And what we do here is we do a mini thoracotomy,

and we use a wound protector and then I remove the the specimen through this

this thing I think we can actually show this on the on either that camera or

this camera are you going to use it the others are you going to widen up one of

the ports or a different mentor academy yes yes I'm actually going to do a

little thoracotomy.

You can recruit your lung first.

Give me this thing.

Give me this thing.

I think we'll do it with the camera.

Can you bring your camera around to this side?

Now that's, you can't shine the light in my eyes.

What are you doing?

The light must be here.

Put off that light.

Put off that light.

Right, now bring the light here.

Wait a minute.

Sit down clearly.

Sit down clearly.

Right, now sit on the Lig, he is not on the Lig, come sit on the Lig please.

Okay, where is your hand controller?

There we are.

Deppers?

You don't want to lose your bearings.

Yeah, just one.

Because this is a big specimen.

Outer?

Yeah, it's okay.

Yeah, okay.

drippers lost and where do you think is where's the rip spreader did you not have thorax still

open now do you think you need to get your chest open where is he good now where is he

good rip spreader how do you think we're going to get the monster out now yeah right

I see Jenny is now gone, very nice, now she doesn't know where the star is, okay, but I think I need to do a semi, all right, yeah, I'm going to switch the light off, okay, now, just a moment, come on, press the button, useless, absolutely,

Stefan, excuse me, we just needed attention. Disconnect from your lungs.

I'm looking for crashes. Give me a grasper.

Come closer. Come up.

Wait a bit. This thing shouldn't have cracked.

Give me another grasper.

I'm looking for my 5mm, the 8mm port.

Here's where you're stuck, that's it, go back, and a grass spur, wait a minute, with the grass spur, come back, that's it, that looks like it, that's it, okay, that's it, yeah, alright, so we got this one there like this, like so,

So, I'm going to open it like this.

It's on the light for us.

Yes, you can... No, wait.

Wait a minute.

It's on the light.

Wow.

It's coming out for me.

Light for me in there.

Give me the basket.

Hold on to the camera.

Like this.

Where is your Lexus?

Yes, I said it should be open.

Make the lens clean for us.

Let's just clean the lens.

You can ventilate.

This is absolutely pathetic.

Give me another basket.

I hope that we have enough space to extract the cancer.

We are now fully prepared.

How am I going to get these things out without a ripspreader?

You better get one.

We are going to have to make this a bit bigger.

I am going to get the ripspreader out.

This is absolutely useless.

Absolutely unbelievable.

I can't believe we are at an international congress

where so many people are watching

and we can't get the operation done.

Yeah, I think that looks very pathetic.

Why don't you get a thoracotomy set?

We're going to struggle to get this thing in here.

That thing is completely useless.

Can't we get the light on in one way or another?

No, what are you going to do now?

Can I get the operation light on in one way or another?

I need a small one, right?

With your SEM number 2, you turned it on the wrong way.

It's not right. What are they doing?

Can you look at the massive thing I have to work with with the SEM number 2?

How am I going to get that thing in that hole?

No, you pressed the wrong thing. Just release it, release it.

No, don't come...

Can I turn on the light here?

No, it's off.

I can just turn it on.

Okay.

Is that the tumour that is stuck?

No, yeah, it's too big so I've got to make the little incision slightly bigger.

Normally we can just get by by putting in two churnies, spreading it a bit open and getting it out.

We don't usually, you know, use a taracot to be set or anything like that.

but in this case we're going to have to definitely widen it a bit I'm going to

put in a rib spreader just put that back in there because the tumor is just way

too big to get out okay so we're putting that back in there

You know, this massive thing in here, this is a joke.

No, not saurini, it's potatoes.

A little bit in.

And it's in.

This is skanda.

Yeah, loosen it.

That's fine.

See, it's deeper.

How far is that?

Sorry about that bit of a delay, but this is a very large tubus.

Delivered.

And Wang, I must compliment you, especially if we're reading to an article by Wang that

compared the minimally invasive surgery for this case, Avril Lewis, and the open.

Besides others, it compared the timing.

It was talking about over 200 minutes, the minimally invasive, and nearly 300 for the

open.

You have done the abdominal part in one hour and the thoracic part in 55 minutes, 15 to get out of the specimen, and one hour of rest.

So it means that you're great, I mean, clean, nice, no blood loss basically, expeditious and fantastic, technically perfect.

We don't even order blood for the patients anymore.

All right.

All right.

And now basically we're just going to suture up and that's the end of the procedure.

Yes, I am, besides all the compliments for the excellent operation, procedure, and thanking

everybody.

I just ask permission, just in case you have a few more cases, we can still keep the connection

if you like, if you want to show some other cases.

A hundred percent.

Thank you, Peter, and thank you, everybody at the Congress.

I hope you enjoyed that.

Thank you very much.

I'm waiting for your call.

I'll call you tonight. And we can speak about Rossi.

Absolutely. Well, we still support him. We'll talk about it.

Yes.

Okay. Bye-bye. Say hello to everybody and to all your staff and nurses and South Africa, of course.

Thank you very much.

Okay.

Bye-bye.

Sorry, one thing. You think you – so we're losing the connection now, or you want to show us some other cases?

No, this is our case for the day.

That's it.

All right.

Thanks very much.

Bye-bye then.

Thanks again.

Compliments.

Bye-bye.

Bye-bye.

You too.

Bye-bye.