F. SEOW-CHOEN - Laparoscopic anterior resection with less ports

Hello. Hello. Hello, good morning. Buongiorno. Buongiorno. Great Italian language. So thank you. Yeah. Thank you very much for being with us today here in Rome on behalf of Professor Palazzini. I just want to thank you for staying with us. Thank you very much. Thank you for enjoying your event this month. So Professor Shoshone. Did you see all the girls here? No problem at all. I can see you very clearly.

and also the audio is perfect.

That's good.

Do you want to see all our girls?

They're all waiting here to be seen by you.

Well, perhaps our technicians can do something about this.

I don't know.

My name is Grandi, and on behalf of Professor Palatine,

I just want to thank you for staying with us.

Just hold on one second.

Thank you very much.

Hold on one second.

All right.

okay just hold on one second so we just to put your images on the main screen

And someone is going on the back, on your back.

It was very low.

That was simply great.

And I just told you that about 9,000 people

were looking at the images streamed on the internet.

And the internet address is www.laparoscopic.it.

And your lecture as well will be on the net.

so the technicians are telling me that everything is okay so you can start your

lecture whenever you want hold on one second okay just go ahead whenever you

want thank you very much thank you very much now just thank you again for this

opportunity to participate in our Congress I want to thank especially

professor Palazzini and your committee for asking me to give this lecture now

Now, today I want to talk about laparoscopic colectomy with minimal ports.

The reason I want to talk about this is because I think there's a tendency for all of us to make big incisions

and even for laparoscopic surgeons to make many holes or many ports when actually we can start with less.

And we see now the tendency with nodes as well as with single port access to do less.

Yes. So when we talk about laparoscopic surgery, we have to decide on the best approach for the patients, best in terms of healing, best in terms of cost, of course, best in terms of lowest complication.

And of course, you make a big wound that's easiest, that may be the cheapest, but that may not be best in terms of healing and recovery.

So when we discuss laparoscopy, we have to ask ourselves, under my hands, in this hospital, which is safer, which is easier?

And this, we shouldn't just refer to published experience of other surgeons.

But we should look at our own experience, our own skill, our own background before deciding.

Now I want to go straight on to the lecture and then straight on to the laparoscopic video which

takes about 20 minutes. Now this is not the best video but it's just a video to show an average

case in my experience. Now this is what we would see as the previous laparoscopic wounds, you know,

extraction site, a couple of port sites, maybe one more here which is not seen. But now nowadays,

days you know we I basically do laparoscopy extraction site always

through umbilicus one incision port side here one port side here you see it's

almost like a normal person I want to show you some of this of this port sides

and external view and then show you a video now this is anterior resection

using three ports one extraction port and a camera port right leg for support

and the right lumbar port and that's all we are using you know for most of our

operations and then here is one an ultra low anterior resection again extraction

port and camera port one lumbar port and one right leg for support you see so

again another case just to show you this straight after surgery and this is just

some video sorry some pictures to show you operation in progress you see and

also we only have one assistant and one nurse to help so minimal manpower usage

Now I think for female patients, again to decrease spot size, we use a uterine manipulator.

Basically this is inserted into the cervix and pumped up and we can manipulate the cervix away from the operative side

by use of an external device like this inserted here and so the assistant can just manipulate the uterus.

Now what we do is after we have mobilized the tumor and the colon,

we exteriorized through the through the umbilical port and then we resect the tumor and once we have

done that um we then put in our our stapler head put the colon back in and then close up the

umbilical port again reinsert our camera port so that we can continue with surgery and that way we

can have this incision as small as possible you see it looks just like a big umbilicus that's all

and two working sites and even right colectomy we're doing the same one

assistant and one nurse and see you see here this is how we do the right

colectomy and even for splenic colectomy that's our incision extraction site two

working ports total colectomy sometimes we need one more working port but again

a minimal of ports you see and here you see even the total colectomy we did with

three ports extraction port and one right port and one left port this one just to show you

this in fact was a lady that was quite unfit and we in fact just did what i call no laparoscope

keo surgery we just made a small incision umbilicus we removed her left-sided tumor and

without a laparoscope because she was unfit for prolonged anesthesia so really in the

cost-conscious environment the safer surgery easier surgery should be performed but that's

not necessarily one where the wound is largest or the ports are most or where there are a lot

of assistance around but it is the one where patients are most likely to get best results

and the fastest track back to normal life and there only the particular surgeon in the particular

environment with the particular patient can decide so now i want to just show you a video

okay here we are now it's gonna go on to this video okay now this is just show

you where put in our camera port so we are just visualizing the whole there's a

small cyst in the liver and but no metastasis and we're just looking around

having a look in the in the inside of the patient's abdomen this is an edited

video so we are no we are not showing you every single step but just the

essential step so you're looking at a pelvis now this is the right colon so

we're putting in our first port okay which you can see is a bladeless and

made by Johnson & Johnson who are supporting our transmission today with

kind regards to them and then here we put in our second port again you see

this one is a reusable so it's a 5 mm um reusable pot and here you see you can see the uterus

and you see the rectum and you see the tumor here okay it's um probably a early it was early tumor

we can see but uh there's no infiltration of the cirrhosis so we're just looking here just

just looking at the rectum and here we have started to mobilize you see the

plane of X of starting we use a harmonic scalpel is a very good instrument for

this get the line of reflection of the parietal and visceral peritoneum over

the and you see a limb note here okay but that's what benign limb note which

was in this case and we just cut down with the harmonic scalpel and you will

will see this is a right plane just behind the inferior mesentery or the superior rectal. I know

most of you there are laparoscopic surgeons, so we will just do a quick one just to show you. You

can see the inferior mesentery and that's the plane. All the nerves are in this plane here.

So as we lift this up, we just use sharp as well as pushing motion to push all our vessels

muscles and nerves posteriorly. As I said, this is not the best video, but I think it's good to

show an average video of what we do. You can see the left ureter there, and this is our medial

to lateral approach for laparoscopy. You can see the ureter very nicely there, contracting away,

warming itself down the left leg okay now it's not my habit to skeletonize the

inferior mesenteric artery just because I don't see a need to actually do that

and so far we haven't had too many problems now of course if there are big

lymph nodes there we will go a bit lower but as you know all the major studies

have shown that a high or low ligation really doesn't make much difference now

Now, you can see here we are directly attacking the inferior mesenteric artery with our harmonic

scalpel. We don't use staplers for that. And in my experience of many cases now, we haven't had

any patient who had delayed bleeding or bleeding from this method. Now, one caution is if patients

are atherosclerotic i would be very careful with just using harmonic scalpel because the

plaques atherosclerotic plaques do not sit very well and and these can sometimes give way

other than that i think the harmonic scalpel is very safe to use in such situations and you

actually save the use of a stapler so i'm not sure if my host here today likes to hear that but still

the harmonic is good for that purpose now once we finish with that artery we then do the vein

and once we finish with that we can lift the whole rectum upwards you can see

that we can see here the reflection on the sacral pulmonary and then we can

very safely then just cut at the right plane there you can see the avascular

plane there and you can see I'm still using two working ports yes or one

working port on my left hand which lifts the rectum and the cutting harmonic

scalpel port to do the cutting and the dissecting and as you can see a sharp

movement anteriorly gives us a plane in order to dissect okay and we can use

both sharp as well as pushing under vision there's no danger of tearing in

the tumor planes with this sort of movement any tumor that seems to be

thicker or a bit stuck then we can cut it quite well with the harmonic okay so

now once we have thinned out the vessel we can then start dissecting it here we

can again you see we're dissecting on the right peritoneal reflection and just

moving sorry here we have now gone back to the sigmoid colon on the left side

and dissecting the lateral peritoneal reflection now I do we do this after we

we have completely mobilized the medial side so that our colon does not become too floppy.

Now, in cases where the colon is badly adherent, we might sometimes have to do this first.

But in most situations, I find that we can do this after we have mobilized the medial side.

So here we are mobilizing the lateral side.

You see a bit of bleeding.

We can easily just catch it and just use a harmonic scalpel to stop that bleeding if we deem necessary.

So as we do that, we now go up.

and again you can see how with economy of instrumentation just with two pots

one a working pot for the harmonic scalpel and the other one left-hand pot

which I use for the for retraction we can easily take surgery a step at a time

now my assistant was usually my nurse just holds a camera if I need her to put

put in a third port, that can be easily done as well because she has a free hand and I don't have

to get more assistance, which of course in our practice scenario may increase cost for patients.

So once we have freed the colon on the left side, we go down the left side into the pelvis. You see

here the uterus, okay, now it's lying flat and we can't see beyond that. So now we're going to just

insert the uterine manipulator once we finish this part you see here the ovary

okay you can see how this is this will work right this is the uterus I see

normally we would in this situation have to put in another pot just to support

the uterus you know and the and the ovary if I if we put in are you trying

to manipulator we can we can easily just you can see a big limb not there as well

here in this case as it turned out this lymph node is actually benign as well you will see

um now okay i think we have actually um got enough distance here and we come back to the left side

okay uh we are way below so we don't have any problems here and we continue to dissect the

peritoneum on the right the left and then a posteriorly so that we have enough distance

I hope you can all see this clearly. The line of division, you see with the harmonics couple, there isn't really too much of a bleeding.

And there is minimal lateral damage with this sort of ultrasonic heat source.

Now, if you can see there's a right plane, you're not dissecting into the mesorectum so that you can get a good mesorectal clearance.

You can see that that's the plane there that we are cutting.

and we can then we can change now I'm still retracting this with just one left

hand retractor okay we can we can use this to retract and to cut or we can

move that left hand port further down okay we just we just want to look okay

now this here we're just checking to see now what we are doing here is we feel

that we have enough dissection already okay so now this is i but we have to dissect some so i'm here

i'm putting the uterine manipulator in via the vagina and you see um how we can lift the uterus

upwards like so all right see the the whole uterus the whole uterus can be lifted way up

away from the from the menu from the operative site here we've got any pots

in the in the abdomen for you trying manipulator okay we'll just wait for the

uterus to rise to the occasion okay so you see now the whole uterus is now you

know well away so that we now have lots of space to continue our dissection you

You see the uterus is lifted up there, right up, which unfortunately, my friendly neighborhood video engineer hasn't shown us.

We'll see in a second again.

But here we are cutting the left side of the rectum to get further dissection.

Still, my left hand port is retracting the rectum to the right, and my right hand holding the harmonic scalpel is just dissecting the rectum all around.

Okay, so you can see the mesorectum is well preserved. There isn't too much of bleeding. There's some wash obviously that we have used to wash. And here we're just moving in. You see, again, just these two ports that we've been using. And we can cut right in the right plane there to get more distance as this is a tumor is rather low.

okay there's um and then we'll go you see the uterus is just lying up there because of this

of the uterine sound that we have put in we can manipulate it side to side you can see the tumor

here so we are dissecting a bit further to get a bit more distance to ensure that we are clear

now this this is actually my first time seeing this video and it's cut forth okay so now we

are finished on the right side we're just going to the left side again to cut a bit further down

you can see with the uterine sound there the uterus is well out of the way and with a left

hand just holding the retractor we can cut very easily and readily in the right plane so you see

we can actually do with few assistants we can do with very few ports and yet get a very nice view

we want just has to be confident of what one is doing and confident of the instrument and

confident of our abilities to do what we set out to do okay so i think here we are really quite

low we are as low as we can um we would like to of course you can go lower if you like and just

cut around um but you can see that even if we have two ports technique doing an ultra low anterior

resection in a patient of wide pelvis or thinner patient is not difficult. In a fat male, short fat

male with narrow pelvis, it may be difficult to do this with two pods. Even in a short fat male,

even three pods is quite difficult or four pods can be quite difficult. In a really low

cancer in a very fat male, I would actually recommend hand-assisted so you can feel better

which helps dissection or else to do a robotic dissection of the lower rectum i think if one

wants to use robotic it's really i think only useful in ultra low anterior resection most of

the upper parts of the dissection the inferior mesenteric artery and so forth can be easily

dissected by a laparoscope and then we come to the last part we can put in the robotics to do

that because robotic otherwise to do whole robotic surgery for both inferior mesenteric artery

splenic flexure, descending colon, splenic colon, and then to adjust, you're gonna waste a whole day

doing that sort of thing. So if you want to have to do laparoscopic robotics, perhaps to leave the

robotics just for the ultra-low part of the dissection. So here we see, we can see very

clearly the fat nodules for this patient, and we're just dissecting a few more centimeters

meters of the lower rectum to get further clearance I think we're going to

we're about to end soon we will dissect a bit more anteriorly because this is

really we have enough distance around the tumor or below the tumor okay now

we're just dissecting the back posterior a little bit more you can see the

mesorectal buttocks there okay these are the bit of the anal coccygeal you know

facial loose area tissue and again you see the whole operation has been

performed just with the aid of the harmonic scalpel and one other retracting

equipment you can see the loose area tissue there very clearly which we are

are now just pushing forwards and we can see here the pelvic floor the levator a9 coming up okay you

get an anal coccygeal ligament which we are cutting you can see the mesorectal buttocks here

all right you can see the levators and there we have gone through valdez fascia valdez fascia

okay now we have done that we feel the dissection is complete up we are way below tumor so i put a

cross clam now we're going to do some washout rectal washout by my assistant and once they

have done that okay now i'm my retraction is with this clam and i'm i put echelon 60

which is another johnson johnson equipment um um okay then this equipment you can see it's not

roticulating but because we put it low down in the pelvis we can actually get a very low

transaction just to make sure that we have enough adequate margins there and we are transacting it

with the echelon 60. um in this case it seems that there's a little bit more of fat on that

side which is not transacted so we're just going to change the blade all right um and then we're

going to just cut it off for more time in fact at this stage this is probably just fat and we

wanted to use a harmonic to cut across that that shouldn't be a big problem as well but in this

case we felt that we should just transect it to make doubly sure that we are not leaving a

perforation if we use harmonic to cut through lumen and then that completes our rectal transection

make sure that the black line here signifies this end of the staple is seen so that we won't have

to use another stapler so here we are we have a complete nice resection we just you can see the

the ureters there, we're just going up a little bit more on the left side, just to make sure

that we have adequate length of sigmoid colon. Now if we do all these things slowly, step

by step, you'll find that you don't need too many ports. This is just resecting a little

bit more, just a little bit more of the left paracolic reflection, peritoneal reflection,

action which we're just doing just to get more length this is of course you

can see this is the ovarian vessels and here we are just getting a little bit

more length on the left side you can see here a very large dilated stomach there

hanging down okay that's transverse colon there okay so here

Here we are, we are just putting a few more finishing touches there to free that pedicle

over the transverse and over the splenic flexure, just to make sure that we have adequate length.

When we do this, we've got to make sure we're not cutting off the marginal artery, otherwise

we leave ourselves with some trouble in that we have to go back in and mobilize more colon.

Okay, now what we have done is, we have actually then done what we showed you earlier, we make,

we deflate the abdomen we open up the umbilical cord we extract the tumor we

transact the colon we put in the the head of the CHD in this case a 29 and

then we attach it we put it back into the abdomen but I show you earlier and

then we read in softly the abdomen and we use a CHD 29 to introduce back into

the rectum and we do a join up like so once we see the orange of the stapler you just push it

down and then we join it up completely like so so we haven't showed you the external view in

this video but I showed the external pictures earlier where we exteriorize the tumor and then

we put in the stapler head and then we put back the colon into the abdomen every insufflate and

that's that's the end product you're seeing so now we have done the anastomosis in this very same

patient we haven't edited the video from various patients it's all one patient as you can see from

the video um as i said this is just a average video we want to show you our technique for doing

this procedure um and then we put back our intestinal clam and we just fire okay we put

back internal external clamp we check the anastomosis and if we think that we need to

free some more just to get adequate length we can go and do that which we are doing here

okay now that's probably enough um okay so you can see this is this is we're sucking out the

water having a good wash and sucking out the water you can see the joint there very low joint

very low joint and adequate okay we just check the anastomosis with with Alden

insufflation here we just and that's okay so we we take out you trying

manipulator and we just put in a drain as this is the ultra low anterior

anastomosis put in the drain the drain is put in via the 5mm port and

extracted through the 5 mm port and that's the end of the operation so this

patient would have just two working ports and one camera port and I think

this patient in fact went home on a third post-operative day so I would say

with just one assistant and one nurse and two working ports and one camera port

one can do an ultra-low anterior resection so I think if operation is done a step

at a time anything can be achieved with good results thank you very much thank

Thank you so much, Professor. We really appreciate the skill you used to perform such an operation with not so many parts, you see.

There was a question from the audience. What about the drain? When do you normally remove it? Do you wait for bowel movement?

No, the drain, I'm not very worried. This drain is just to make sure that there isn't any excessive fluid or blood.

so normally the first or second post-op day i remove it that i i forgot to tell you that at

the end of operation i always put in a rectal tube which is a foley's catheter through the anus

just to decompress the rectum and normally i remove that on the first post-op day

on the first day after surgery i give the patient uh small feeds which means feeds less than 300

mils clear water if patient retains that second day i give the patient full feeds which means

they can drink what they like when they like and then usually by the third day the morning they

have breakfast now i don't give them any fiber at all no fiber no vegetables no cereal for at

least two weeks but i give that they can eat steak they can eat fish they can eat rice or noodles

pasta anything they like except fiber from the third from on the on the third day morning and

if they are okay they can go home on the third day afternoon or the fourth day so they are in

in a fast track theory of course yeah as soon as long as can take it if they find that they

have this tension and slow it down but normally the average 95 percent of patients will go home

on a third day after surgery that's really great and astonishing so professor on behalf of professor

palazzini i just want to thank you for staying with us today and thank you very much and thank

you professor palazzini yes as soon as i see me because he's running everywhere you know it's a

a really huge congress and so it's not so easy. I really hope you could take a look

to the internet site and I repeat it, www.laparoscopic.it just to check the feeling of this great, really

great event and we really are honored to have had you as a part of it. Thank you very much

Professor. Hope to see you very soon in the future, hopefully next year. Thank you so

much.

Thank you very much.

Thank you.

Thank you.