P. WINTRINGER Total Laparoscopic, Total Gastrectomy with en-bloc lymphadenectomy for C16.2 adenocar

So I'm talking from Bordeaux, my name is Pascal Winteringer and I will first show you a technique

of fully laparoscopic total gastrectomy with en bloc lymphadenectomy and also the reconstruction

which is also a difficult point, the iso-jejunal anastomosis.

So this is edited video and afterwards if we have time I can show you a more formal

presentation on state-of-the-art of pancreatic surgery laparoscopic pancreatic surgery i'm here

in bordeaux with two international fellows yes total yes total okay

So two films, bigger and smaller, and they have channels and they listen to the one they want to follow.

According to the program that interests them.

So unless they exchanged, but until now it was like that.

It's a band of attendants in fact.

Yeah, I think so.

Because there was both the live, the live sometimes there are times less.

They present it and then participate.

Yeah.

No, in fact it's the moderator that I would have, so they introduced me.

Is it an assembly?

Yes, it's a professor that I know from the Sapiens in Rome called Giorgio Palazzini

who has been organizing this since... I think the first time I had to do this in 2000, even before 2000, because there was the millennial one.

And so I think it's just that last year I didn't participate. Usually it's always in May, and one year it was in...

They had financial problems, they didn't do it, and they did it the year after in September.

I follow you, I follow you, you're always there.

But it's funny, because at the end of the vision,

the tattoo was like, ooh!

There's the magic side to it.

Ah, yes, it's like that.

What's great is that I can take my hand and...

Okay. Yes?

Now I can hear very well, and the image is clear.

The image is clear.

I can give you also some data,

because I heard the... Yes, I...

Yes.

Palazzini started in 1989,

in the first time for this Congress.

And now we have about 2,400 soldiers coming from all Italy and about 40 different operations rooms from Italy connected with us and 60 operations rooms connected from all over the world.

So you can start with the online show.

Yes.

Could you just lower the gain of your microphone?

We have a little...

Okay, sure.

Okay, sure.

If possible.

Okay.

Are we online now?

Yeah, yeah, yeah.

Can we start?

Yeah, yeah, sure, sure.

Okay, so I will make the presentations in English, speaking slowly.

You can interrupt me anytime you want.

It's an edited video, so we can freeze the video to discuss about it.

So, I'm talking here from Bordeaux.

In the background you see the old port of Bordeaux.

Bordeaux is a very nice 18th century city, very sunny.

It's a bit like Italy, a lot of Italians here.

And I'm making this presentation with two international fellows we have on a regular basis.

Here, Dr. Paolo Campello from Fortaleza, Pernambuco, Brazil, and Dr. Freddy Pereira, who is from Venezuela.

They are staying with us on kind of fellowships.

Okay, can I start?

Yeah, yeah. What do you want?

Okay, so I will show you first a fully laparoscopic totem.

I don't know what to say. It was a rare case in which the intraoperative images were the diapositive schema.

I understand.

Is the image good or not?

Yeah, very good.

Yeah, very good.

That's true.

Comment?

Okay, can we start?

Sure, sure.

Sure, sure.

Okay, so I will show you a fully laparoscopic total gastrectomy with en bloc lymphadenectomy.

When you want.

Can I start?

Can you hear me?

Yes?

Okay, you can start when you want.

Okay, I start with the fully laparoscopic total gastrectomy, okay?

Okay.

Okay.

You have the picture?

Sure, very good.

Sure, very good.

It's starting.

So this is the exposure.

study from Dutch surgeons published in 99 that showed there was no real survival advantage but

a much more higher morbidity but a real Japanese d2 resection included resection of the tail of

the pancreas and if the spleen and of course the morbidity was higher here I want to show you a

total gastrectomy with extended lymphadenectomy removing all the lymph nodes from all those

sides including the 11 sides and even the 10 in the hilum of the spleen

without removing the pancreas nor the spleen and it's possible with

laparoscopy so let's go and do this procedure laparoscopically like always

well this is the exposure the first step of a laparoscopic gastrectomy is to

assess there's no peritoneal mats you know that they can be missed especially

especially in whole-body cancer or if it's an N1 cancer,

it has been shown there's a higher probability of peritoneal mets.

And even if TAP scan now can assess them,

the best way to see them is laparoscopy.

So laparoscopy is always diagnostic in the first place.

Here you see the opening, the freeing of the gastrocolic ligament,

and the momentum stays with the stomach, it will be removed en bloc.

And as you can see here, by a very close-up, by the magnification of the endoscope,

you can see the proper plane between the mesocolon and the posterior mesogastric.

And so you can make a very anatomic dissection.

I would even say embryological dissection,

because this is the embryological adhesion plane from the original movements of the fetal bowel.

And as you will see, so this opens lesser sac.

Here is dissecting the fatty tissue under my forceps.

You see the pancreas appearing.

And the point is to leave what's under the scissors here, which is here's the colic and media artery and veins.

leave off, of course, everything that's mesocolic, but remove all the fatty and lymphatic tissues pertaining to the stomach.

And working very close up, like here, you have a magnification, here you can see the right colic vein,

and we remove all this tissue on the pancreas, and the dissection will even start inside the capsule of the pancreas.

So this is a really extended lymphadenectomy, as you can see.

You can see the pancreas very nicely.

It's a little...

Do you always do the pancreas to protect the piece?

We're not there yet.

No, no, I will show you.

Usually, interestingly, if there are questions,

I prefer to freeze the picture so I can go on commenting the section.

For the removal of the specimen,

Usually I enlarge slightly one of my lateral protocular wounds, especially the ones with the 12 mm port for the stapler.

And usually, except of course if it's a very big specimen, a large tumor, on most occasions you can remove a whole stomach through a 3 or 4 cm incision, strangely enough.

Especially most of cancer patients, we operate them after three regimens of neoadjuvant chemo or even chemo radiation.

And sometimes, this patient, I will tell you about the PTNM in the end, but you will be surprised.

Let's go on. So you see here, my forceps has the capsule of the pancreas and the dissection will start inside the capsule of the pancreas.

removing all this posterior peritoneum.

Here it's dissecting the right gastric vein.

The vein going leftwards is the right colic vein,

and under it is the gastrocolic trunk of Henle, which we leave.

And now the dissection goes on on the pancreas

towards the termination of the gastrododinal artery.

And you see this is easily done with the magnification.

We work really inside the capsule of the pancreas to remove every single possible fatty and lymphatic tissue here.

The dissection goes on towards the head of the pancreas here, working on the pancreas, not inside of course.

Here's the duodenum appearing.

You see those plastic polyurethane clips?

I like them because they are auto-locking.

They're very, I feel they're better than titanium clips.

And the dissection, if you want to do a precise dissection like here,

I use bipolar instrument in my left hand, and since I'm right-handed, my scissors in the right hand.

This is the termination, it's the right gastric artery, or if you want, it's the termination of the gastroduodenal artery.

This is the job freeing the first duodenum from the pancreas adhesions.

You can see here the hepatic artery pulsating in the deep far end of the picture.

That's the common hepatic artery.

So you can even start the lymphadenectomy on the hepatic artery from underneath the stomach.

Here's the origin of the gastroduodenal artery, the one you ligate at its origin in a Whipple, for instance.

Now, moving to the hepatic pedicle, incising the peritoneum here, you see a large, enlarged

lymphatic vessel, and this section now will find back what we previously dissected here,

the common hepatic artery, and this enables to continue the lymphadenectomy here on the

hepatic artery.

At this step, it's possible to transect the duodenum quite far, to be as far as possible from the pylorus,

and this enables to lift the stomach to continue the dissection.

Here's the, we're taking back the dissection inside the capsule of the pancreas, you can see here.

This is the hepatic artery again, and continuing the lymphadenectomy around the hepatic artery,

and here dissecting the portal vein.

And so, as you will see, this is like an anatomic demonstration of the vessel structures, and doing this, we remove all the lymph nodes there.

And you see here, we work very close here on the portal vein, and all the tissue to the right of the portal vein and the hepatic artery will be removed.

This is a full extended lymphadenectomy here of the eight, number eight lymph nodes.

So this makes it possible to continue upwards towards the right gastric, the left gastric artery.

Of course it can be a little bleeding. The bipolar here you see working is very useful to make this very precise dissection.

And it's very, here what you see is an enlarged lymph vessel which you hardly see even in open surgery.

I mean, this is the magnification from the endoscope.

You can work very close up, very precise,

and I feel you do much better than you ever did open.

This is the full completed lymphadenectomy on the hepatic artery.

And moving upwards enables to dissect and to continue the lymphadenectomy

for the number three nodes and also here,

identifying the left gastric artery close to the to its origin you see the

hepatic artery under my scissors the splenic artery will go to what size those

circles I'm not doing the anastomosis yet maybe we can discuss this with the

the second movie on the reconstruction if you agree let's stay with the

dissection for now, if you're okay for that. Here, the point is the artery is quite thick,

so my clips were a bit lousy, so I prefer to do a regular suturing with a 2-0 Vicryl.

In the case of a very large artery like here, you could use a liner stapler with vascular staples,

of course the gray cartridge after transacting the vein the dissection goes on removing all the

lymph nodes here down to the outer and the right cruise very very good very very good you see the

uh you see what you get i mean this is very extended lymphadenectomy i think this you do

much better laparoscopically and there's even more it's but there's even better to come when

and you will see the dissection on the lymph,

the number 11 nodes on the splenic vein

without dissecting the pancreas, you will see.

So this works towards the right crux.

You can see here, identifying.

And here is entering the posterior mesosteum

under the cardia and the lower esophagus.

Here we are inside the, around, on the other side,

on the left crux.

You can see the pulsating artery here is the splenic artery,

here under my my process this will finish from the other side from from the

left side of the stomach here you can see residual a little bit of sclerosis

on the splenic artery we can dissect it very close to the artery and we can even

work inside the outside layer of the arteries usually the arteries are not

invaded unlike the veins and here we start the dissection of the splenic

artery removing all the nodes here on the splenic artery but my point is to

leave the patella of the pancreas and just remove all the nodes here without

any pancreatic surgery this lady had a cancer in her in the four centimeters

needs are below her caria. It was a T3N1 in the first place. When we first did a laparoscopy

and it was stuck, she got six months of TCF regimen. And there was such a response that

we decided to go to a total gastrectomy. And there was no peritoneal meds, no capsule liver

mats and we could proceed. Here you can see the intertanglement of the

splenic artery and veins and it is possible to dissect on those arteries

without removing this pancreas and removing all the number 11

nodes here and even the nodes in the hilum of the spleen. Bipolar and

scissors is the most precise way to do this. If you use a ligature or you use an

precision it's it works i mean but you lack this very tiny precision you can have here and you see

this is the splenic artery and this is the splenic vein and you can dissect on it you remove all the

tissue here leaving nothing here's the use of the five millimeter ligature of course it works very

nicely is the picture always okay yeah yeah and now we finish the dissection here uh on in the

on the esophagus and in the end transacting the gastro splenic ligament there's a little ischemia

of the tip of the the spleen but that's not a big problem and you can see the dissection here

full dissection of muscles here well that's it we remove the whole stomach and all the lymph nodes

and that's the end of the dissection on the gastrophrenic ligament and this is now the

the stomach is ready for transection and to do the anastomosis.

That was the first video and if there are any questions now, we can answer them now

and then we can, if you have any questions I can answer them now, this is for the resection

and I have a second movie to show you the tricks I have to do the anastomosis.

no question from the audience okay so we can move to the we can we will move to

the reconstruction most I saw many because we don't do many gastric cancers

of course this is it's still a very aggressive cancer with a high mobility

high mortality even and but we don't have the cases the Japanese surgeons

have. Kitano has a review two years ago with 2,500 cases. We had a paper in 2005 on 50

cases, which is much for us, I mean. And many patients don't get operated. We try to operate

only as a curative intent. We will discuss this also for pancreas surgery, it's about

the same. And many surgeons, Japanese surgeons who do this surgery, they do the dissection

laparoscopic because the dissection did you get this high precision for the

lymphadenectomy and some would do a mini laparotomy to do the incision to do the

reconstruction and to remove the specimen anyway but you can do this

totally laparoscopic and I will show you this and not just just now in this new

other video so this is the end where we left it this is the prepared stomach

What I do is I use, I try on the oesophagus always to use at least a 25 circular stapler.

And the trick is here to open the oesophagus to introduce the head of the anvil.

And the anvil is, I put on it a stitch with a needle.

So I introduce it inside into the lower oesophagus.

I put it as far upwards as I can.

and I with the stitch I put a stitch at the side of the esophagus where I want

to transect it so this will be a trans suture anastomosis a bit like you do

for low and for rectal anastomosis so I here I transact the esophagus with a

just a regular line of stapler here blue cartridge now I would use the the

violin new cartridge from from covidion which was a bit larger staples the you know that the

esophagus is very thick especially the submucosa and now the trick is to retrieve the anvil

with the stitch on the staple line a bit like you would do a trans suture but i don't like to use

the trans oral way to do it because this is non-sterile and but this way is totally sterile

of course the stress is not to lose the anvil so you have to put a very good

stitch there and now we gently pull on the anvil so you have to do this very

carefully and I always use a 25 at least 21 is too small it's better to put a

purse string here to be sure that you your anastomosis will be fine and at

At this step, we will create the Roux-en-Y loop, working back to the inframesicolic region.

This is a note of video.

This is creating the Roux-en-Y.

You saw the ultracision.

Laparoscopic surgery, you have to be like MacGyver.

You have to use anything that's possible, what's the best for you, what you want to do.

So this is the Roux-en-Y, just on a regular basis, very easy.

On terotomy, you make a lateral-lateral.

I use white cartridge as you see. This we learned from bariatric surgery. It lessens the probability of bowel bleeding. If you use a blue cartridge on the bowel, you might have intraluminal bleeding. Always check for absence of bleeding.

And not to narrow this through and why usually I close the introduction hole with just a regular running 2-0 vitral suture.

I prefer to do transmissocolic.

This lessens the risk of internal hernia.

I had a patient who died three years.

He was disease free after three years after a total gastrectomy for cancer

Because of internal hernia and strangulation and he he was referred to me late with with bowel ischemia

He was a cardiac patient 82 years old and he died of

mechanical obstruction

Disease free at three years. So this is really a pity

always close the defects always close the

the mesenteric defects, this is a major issue.

I think this is very important.

And we know from, and so you make a lot,

you enlarge the 12 millimeter port

to introduce the circular stapler, the 21.

This is a bit tricky, this is a bit difficult.

You cannot control here the issue of the anvil

and there's a risk of tearing the place

where the bowel is perforated.

And then it's a regular transducer, terminal lateral anastomosis.

While you close the stapler, you have to check for absence of twisting of your bowel

and also absence of incarcerating anything else inside the anastomosis.

After full closure, firing, reopening and retrieving of the instrument,

you can check the donuts here.

They look full, but I will check them outside, of course.

And then transecting the little part, the little dead end of the bowel, you can check the anastomosis. If there's any doubts, you can do a methylene blue check, you can put extra stitches.

and here of course removing of the specimen for this slightly enlarged incision so usually we

enlarge the incision to three four or even five centimeter is if needed so it doesn't need an

extra fennel steel incision I mean and the whole procedure is done with five pores this case was

There's another case with an en bloc removal of the spleen.

That's to the gastric surgery.

Do you have any questions or comments on this?

Yes, I would.

What do you think about the lateral to lateral esophagus digenital anastomosis?

You can do it.

It is supposed to be easier.

What I don't like is that the thick layer, the muscle layer of the esophagus, they are vertical.

And I feel maybe it's not that safe.

But I know it works.

I feel quite confident with this circular stapler because it's the way I did it open.

But I would recommend not to use a 21 stapler because a 21, you have very small doughnuts.

And the problem with the esophagus, what is resistant is the submucosa and with the 21 stapler I feel there's a risk of having a poor anastomosis. I always try to use a 25 and in open surgery on occasion I was able to use a 28. But also this depends of course of the thickness of your bowel, depends on the size of your bowel.

you're sure you're sure and and also I'm not so sure that is kind of our master Moses it's

really easier the lateral lateral lateral it's supposed to be easier yeah but the problem is

yeah what is easy is to fire your stapler but you have to close the incision and then you have to be

be sure that you see exactly what you're doing, that you take the submucosa for the esophagus.

I feel the lateral lateral with a liner stapler is okay for the gastrogegenal anastomosis in a

bypass, but this is not a bypass. This is different. This is an esophageal anastomosis.

And maybe as you noted, usually your anastomosis will be in the mediastinum, not in the abdomen.

So this is a danger. This has to be a fully sure anastomosis. I only had one fistula. I had to reoperate early. And this is something also very important, I feel, about laparoscopy. If you do a nice job, no bleeding, no problems, very clean dissection, there will be no adhesions.

and this is the difference with open surgery when we did open surgery you were touching everything

with your hands you were creating adhesions and that's why the complications like fistula

they appeared after seven to nine days because everything was stuck and the fistula needed time

to come out with laparoscopy you have no adhesions as if you have a complication and this we learned

from bariatric surgery we learned a lot from bariatric surgery you get a fistula

if you have a leak it will be an early leak it will be within two to three days

because there's no adhesions and with laparoscopy also if there's a problem

it's much easier to go back laparoscopically than to do a redo

laparotomy so if there's a problem it's a suspicion of a leak or suspicion of a

complication you do a CT scan and if there's something you go back you go

goes straight back laparoscopically and if you re-operate early for a complication it's easier

to handle so if you have a leak on this anisotretinal anastomosis and you operate early

you could suture it with a drain you could put a t-tube you could do anything but you can do it

early unlike when you did it open and when you had you operated late with a lot of problems already

So, I think this is also something very important about lap surgery that you can reoperate earlier

and settle the problems immediately.

Okay, thank you.

Any other questions?

No, you can go home.

You have a gastric champion in Italy, that's Cristiano Russo.

He was the only one who did a randomized trial comparing open and laparoscopic gastrectomy.

And he showed no difference.

He's our Lacey for gastric surgery.

I'm so sorry, but...

I'm so sorry, but...

But today we...

But today we...

Richard is not here.

Richard is not here.

You're going.

I...

Yeah.

I know.

He was in Rome.

He's in Milan now or something.

Yeah, sure.

Yeah, sure.

Anything else on gastric surgery?

We have two papers on that with my partner Deloitte, but they are old papers.

We don't do, in France, it's not an increase in cancer, fortunately, because the mortality

remains high.

But we have even worse.

I mean, this is pancreas surgery, pancreas cancer.

But this, the patient, the first video I showed you was a 75-year-old lady.

she had a M plus cancer and she had six months of TCF taxol carboplatin and fluoroacil and at

TAP scan there was like total response and that's what's the first operation I showed you and on

On pathology, she was YPT0N0, 37 nodes, all negative.

And I didn't operate her the first time because when I first did the first laparoscopy,

before she got the chemo, there was a capsular mat on the inferior border of the segment 3.

And this disappeared completely.

After six months, there was a questionable fixation on the liver, on TAP scan, so I reoperated her after six months to do a left lobe resection, fully laparoscopic of course, and she's been remaining disease-free ever since. It's been a year now.

It's a good result.

It was not a liver mat, but it was a contiguity adhesion and an invadement.

Yeah, but it's surely a very advanced procedure. What about the learning curve?

What is the learning curve? If you're a surgeon, you do the surgery. I never heard about it.

I mean, learning curve is a sort of a moral alibi to pretend that your complications, it's not your fault, it's your learning curve.

whenever you operate as a surgeon you're responsible for what you do and you

should have no my goal is have do the job full resection treat the cancer no

complication and if you don't have complications you don't do enough if you

do a lot of cases you will have complications surgery is difficult there

are complications but what we try to do is as less as possible as low as

possible upon morbidity rate ns and so you do the job good if you start laparoscopic and it's

your stock because there are then you convert and if you feel confident going on laparoscopically

you just go on so i don't know what's the learning curve i agree with you this is the typical

question coming from the audience so you can go hard with the second part with the second part

pardon I forgot that another yeah I will if you are if we have time I need half

an hour maybe maybe more expressions to make your more formal presentation of

state-of-the-art of laparoscopic pancreas surgery okay okay so we can

start this is I have videos and slides so if there's any questions you just

is the end of a dissection after a laparoscopic whipple.

You see the portal vein, under the cannula you see the superior mesenteric artery,

under the superior mesenteric artery you see the left renal vein, you see the vena cava,

and above, slightly yellow, you see the transected hepatic duct.

So this is the end of a dissection in a whipple, and I will try to show you also in a whipple

that you can do an extended lymphadenectomy, not just a regional, but an extended.

And routinely, we try to have over 30 nodes in a Whipple.

And on the left, you see that the dissection in the left tail resection,

and I will show you this in a video too, shortly.

Here you see the files for the cancer figures for 2008.

What you can say about pancreas, it's...

as you see pancreas there's nearly as much new cases per year than as our deaths because this

is one of the this this is even worse than for stomach and that for lung and bronchus so this

you can say that pancreas is still one of the worst cancers at all so pancreas surgery the

problem is especially for whipple it's a very tough maybe it's the toughest and the difficult

Most difficult surgery we do, even open I would say, but of course also laparoscopic.

And so you shouldn't do a Whipple or a pancreas surgery outside an accurative intent.

So the core issue here is to assess the patients for resectability.

And the point is we don't operate, we only operate if we pretend we will have an R0 resection.

If you know from your pre-op workout that there's a chance to be R2,

or two you shouldn't do the case so you know this your ct scans mris might be sometimes useful and

now we routinely use pat tdm pat ct because pat ct makes sure you have no hypermetabolic

fixation outside the pancreas and i'm really interested also if pat ct can show you

petroneal meds because even more than stomach the problem with pancreas then

you can have unsuspected petroneal meds and of course if they're present you

have a general disease no surgery and that's why even if you do open surgery

for pancreas I would advocate and it's the recommendations coming from for this

that you do a lap exploration in the first place so you don't do an

an unnecessary laparotomy.

So you'd only operate if there's absence of distant metastases,

and this you can assess from CT scan and TAP CT,

and no vascular encasement.

But this is not a fixed option.

I mean, if you find this, you put the patient to neoadjuvant chemo,

and you have to re-evaluate.

And some patients might become operable after initial neoadjuvant chemo.

Of course, it's difficult, especially on the right side, as a whipper, and it's still not commonly accepted as even less done than liver surgery laparoscopic.

It seems to be established for benign lesions, especially for endocrine neoplasms.

So, as I said, surgery is only done with a curative intent.

We know that over 80% of the patients will not be cured and they will die within a year.

So a patient who doesn't get surgery with pancreas surgery, pancreas cancer, he will die within 6 to 12 months.

Some patients survive a little longer even on palliation, now with new regimens on gemcitabine, but still it's a very deadly cancer.

Surgical mortalities should be lower than 5.

there is a mortality for Whipple because it's a very complicated surgery. Receptive patients

survive a little more than not operated patients and some have even a long-term survival. But in

general, long-term survival is still less than 20% and a few years ago, before gencitabine,

it was even under 10% or even 5%. It is, as I told you already, it's recommended to do a

staging laparoscopy even if you don't do laparoscopy routinely for do the resection

because you might encounter and I had this so many times I mean you put the endoscope and patada

you have peritoneal mats and then you bite biopsies and you stop because you have an m1

case and this is not curable so you stay with in that case you stay with

with chemo. So the selection for surgery is to get, to be sure you can do an R0 resection.

And this is really a bit more new that you can have kidney, I already told you about

your neoadjuvant chemo or even chemo radiation and eventually a few patients will become

resectable after initial neoadjuvant chemo radiation. Always reassess the patients. You

You have never a full decision.

Here on the CT scan you see un-resectable cases.

I'll go forward.

Laparoscopic pancreas surgery

or even pancreas surgery in general,

you want a zero resection.

This is a prognostic indicator for long-term survival,

for potential long-term survival.

Of course, the tumor size,

and the tumor size also goes with adjacent organs

organs invadement and also with non-R0 resections, of course. And of course, one of the major

prognostic indexes are the N status. Although regional nodes close to the pancreas are sometimes

the patient can be N1 and you can have a potential for cure with chemo radiation also. And in

the future it's you know that we have this for breast cancer it's more and more for colon cancer

it's the molecular profile of the cancer which can make a tape can pretend to make a tailored

chemo like we have antibiotics for microorganisms with molecular profiling of the tumor we can have

sort of a really subtle settlement of to whatever what the best chemo for the patient will be to

have the best possible result here's from the hgcc manual the lymph nodes of the pancreas you have

first on the picture on the on the left all the regional nodes on the pancreas they are routinely

we removed the pancreas, but also the hepatic nodes, the splenic nodes, and the nodes on

the ciliate trunk, and on the superior mesenteric artery.

And I'll try to demonstrate to you on the videos how we do this laparoscopically.

First, this is just a small video to show an enucleation of an endocrine neoplasm.

You can see the tumor here.

Sorry, let's go back.

I'm sorry there was a it's automatic so this was a pancreatic incidental oma in

a young lady here you can see it it's the the hyper density you see on the on

the other part of the picture we use the endoscopic ultrasound this is absolutely

mandatory also for liver surgery you can see the tumor here underneath the

splenic vein and the outer I call it them for you so it was very small tumor

very regular tumor here's the Doppler effect to control the vessels and this

case of course looks and is very easy it's here I use the ultracision I feel

the ultracision is okay for the pancreas you can make a very this is an older

video maybe the quality is a little less than usual and it's very precisely

dissecting this incidental loma it was a non-functional endocrine tumor

differentiated and for this kind of tumor it's enough of course there was no

other tumors in the pancreas the problem is to twist the ultrasound is to check

you're not close to the main pancreatic duct and you don't injure the pancreatic

duct so you look for absence of pancreatic leak and that's the resection

and you see the resection setting and the rest of the pancreas and you leave a

drain, and there can be a fistula if you're close to a duct here. Here I'll show you just a review

of cystic neoplasm of the pancreas. I feel this is important, especially mucinous cystic neoplasm,

IPMN, and solid sort of papillary neoplasm. They make up for 40 to 80 percent of cystic tumors of

the pancreas they are usually found as an incidental finding on ct scan or ultrasound

and what's interesting about those scans those settings or those findings it's they are pre

cancer stages if you operate them as a cystic tumor and still benign you cure your patient

if you have an invasive carcinoma you have the same issue than you have with regular ductal

adenocarcinoma. So this cystic neoplasm, it's the only way to preserve a patient from developing

this invasive carcinoma. And you can potentially cure them before they have a cancer. So I

first show you here a left pancreatic resection. My technique for a suspected or borderline

cancer or a suspected cancer is to remove the splenic vessels en bloc with the tumor

because this makes up for the splenic lymphadenectomy.

And a bit like you saw for the stomach surgery before, it's easy to identify the mesocolon,

which you detach.

Here you see the cancer.

It was a large cystic tumor.

It showed up to be a solid sort of papillary neoplasm in a 45-year-old lady.

And, you know, this is a borderline tumor.

Here you see the mid-colic vein.

We leave, of course.

And the dissection starts a bit like you saw exactly the gastric surgery beforehand.

As I showed you, I work inside the capsule of the pancreas.

And of course, in this case, we will go under the pancreas towards Gerotas fascia to remove the pancreas and all the lymph nodes at this side.

So my technique is to remove the splenic vessels, but try to keep the spleen on the short gastric vessels.

And therefore, you have to keep the gastric vessels on the greater curvature and also

to make very sure not to injure the left gastric vein, which will drain the spleen.

There will be a kind of ischemia, of course, but it has been shown that the survival is

better with the spleen than without the spleen.

This has been proven.

Here you can see the splenic vein and the splenic artery, and we dissect here on, you can see under my instrument, you could see this stratus fascia. Pulsating on the end of the picture, on the lower part of the picture, is the right colic vein and the superior mesenteric artery.

He is controlling a pancreatic vein with a ligature, 5 mm ligature works fine.

Here you can see what's pulsating in the far end of the picture is the left gastric artery and the left gastric vein.

And those we have to keep very carefully because they will be in the spleen.

Here's the left gastric vein.

But here we start the lymph node harvesting on the hepatic artery.

We go back to the pancreas. On the left of my picture you can see the portal vein.

And we will control this planic vein at its termination here on the portal vein.

This is done quite easily, just with a ligature, like you would do open.

Nothing different. Intracorporeal knotting, of course, because you see what you're doing.

I don't like extracorporeal knotting. I think this is why you just couldn't do it.

you don't control what you're doing you just here you do what you would do open

I mean I could talk the the proximal part with with the ligature here I

dissected so I transacted just to pancreas first this is an older video

now I would I would control the artery first so transacting the pancreas with a

just a stapler tissue stapler here blue cartridge I would use the dividing

Now they are thicker and a smaller row.

Here is the splenic artery, quite big, and finishing the lymph node harvesting here on

the splenic and gastric pedicle.

You see what's pulsating here is the right, the left gastric vein and arteries.

As the splenic artery is quite big here, I use a vascular stapler, of course you could

dissect it a little more and then use a stapler.

In the end, you can see here, you can see the gyrotas fascia here.

And the dissection moves towards the spleen, towards the hilum on the spleen,

where the proximal and the distal artery and veins will be controlled.

And the spleen is left a little ischemic, but still vasculized.

And this will keep the immunological function of the spleen.

The spleen is preserved on the short gastric vessels.

There were papers on that.

showing that in any independent of the age of the patient and the pathology the

survival is better you can see Jirota's fascia the posterior fascia this is the

resected specimen with the tumor with the unblocked lymphadenectomy and of

course we will always every cancer specimen is removed through a bag or

through a small incision with a plastic protection of the wound you saw the year

And here the spleen, a little ischemic, but in the beginning, the first cases, I checked them with regular CT scans, and you can see with controlling the spleen like that, you can see that the spleen recovers.

Okay, now to the duodenal pancreatic duodenectomy, or WIPL.

There are arguments to do just a regional adjacent peripancreatic lymphadenectomy,

but especially in the US, it's been advocated to do extended lymphadenectomy,

and this is removing all the soft tissue from the hilum of the right kidney

to the left border of the aorta and the superior mesenteric artery.

There are papers showing there's an improved survival whether you do or not extended lymph

anectomy and some show there's no advantage.

Whipple is still considered as some kind of elite surgery.

World debut was by Michel Gagné in 1994.

This very first world case took 10 hours, was re-operated.

Up to 2009, within 15 years, only less than 150 cases were published.

We had the largest series with my partner Deluc in 2006, and last year a Mayo team by

Kendrick and Cusati presented 65 or 62 really laparoscopic cases.

So this is a laparoscopic Whipple I showed at ACS two years ago.

The start is always freeing the mesocolon and the hepatic flexure of the colon.

The video is okay?

yeah yeah yeah and here it's not a mere cocker maneuver but it's removing all the soft tissue

on the vena cava starting from the right border of the vena cava to remove all the nodes the

posterior nodes at the left lower end of the picture you have the mesocolon and this hepatic

flexure of the colon and here you see we will remove all the soft tissue here's the right

a right genital vein and you see this is full exposure of the anterior part of the vena cava

removing all the soft tissue here removing all the notes here and we work on the vena cava i i

must confess i didn't do this open i only do this laparoscopic you see the uh post the ritual

mesenteric window has been opened you see the uh the genome here and continuing this this section

We will do all the procedure in a supra-mesocolic setting.

It's not necessary to go under the mesocolon

because you can do everything from above.

You see the freed duodenum.

And it's possible to continue here

dissecting all the soft tissue on the aorta.

Here, removing all the caval aortic nodes.

Typically, we have over 30 nodes in a laparoscopic ripple.

which is quite adequate, I would say.

The more nodes you have, you don't cure the patients by removing more nodes,

but you have a better assessment of his end status,

and you know where you are, where the patient is in this disease.

You can see the lymph vessels here.

So we continue peeling off all the soft and lymphatic tissue on the vena cava.

You see fully exposed already, and on the aorta.

He has a small aortic branch to the pancreas that will be controlled with a clip and this

is clipping a small artery and clipping here, dissecting the tissue.

This is the first duodenum.

At this step, following the right colic vein here under my ligature leads to the retromesenteric

and retroportal part of the pancreas.

You can see the limit between the pancreas and the mesocollum.

Here it's controlling veins to the stomach and to the pancreas.

And following this vein will lead you to the portal vein.

Here is the gastric, the right gastric vein, controlled with a ligature.

This is another branch.

And here you can see the portal vein.

That's the way to find the portal vein.

It's following the right colic vein.

and in most cases it's very easy to tunnel under the pancreas here on the

portal vein and here detaching all the lymph nodes here at the inferior margin

of the body of the pancreas you only on the below side of my picture I only

leave what's mesocolon we always try to remove as much as possible lymphatic

tissue around the organ here you can see determination and the splenic vein at

At this step, we control, I routinely do a whipple, a so-called whipple, meaning I routinely

remove the distal part of the stomach.

I feel I have a better lymphadenectomy here.

The problem we have, we can discuss this later, is delayed stomach emptying and the so-called

Longmeier-Parlour's preserving pancreatic otodonectomy.

Maybe you have lower disc, but you still have delayed stomach emptying.

any time you touch the stomach.

This is the end of the lymph node harvesting on the hepatic artery,

a bit like in the gastric.

This is not unblocked. I remove it separately.

Exactly like we saw this in the total gastrectomy earlier on.

It will be removed in the end with the specimen.

And here, dissecting on the common hepatic artery,

you see again, it's really magical with the laparoscope.

you can see the vasovasorum, you can see the lymphatics on the artery here.

This is the superior portal vein again.

And doing this, we will control the origin of the gastroduodenal artery

and leaving the hepatic artery fully skeletonized.

And you can see, you can work close up here on the portal vein

and removing all the lymphatics here on this arteries,

Controlling the greater curvature before transecting the stomach. Always take care to remove any gastric tube here.

Transsecting the stomach, I would rather use green cartridge. The stomach is thick.

And here the pancreas is detached from the portal vein before transection.

And at this step we will transect the pancreas to go on with the dissection on the posterior aspect.

Before that here I control the jejunum by pulling the bowel below the mesentery and transecting again with the white cartilage.

We leave the bowel there before the reconstruction.

Now, I would rather transect the pancreas just with blunt scissors.

Of course, in that you have a little bleeding on the marginal arteries, you can control

them with bipolar or with a ligature suture.

I would not recommend to transect the pancreatic duct you see here with a harmonic because

you might seal it off.

so usually always transacted with sharp scissors and now what's left is the

what's sometimes difficult in open surgery you can see the limit here

between the pancreas and the superior mesenteric artery and so now we can

dissect on the superior mesenteric artery removing all the lymph nodes

what we sometimes call the retro portal part of the pancreas and the ligature is

on the portal on the superior mesenteric artery you see pulsating there there

will be some major vessels you can see the superior mesenteric artery here the

portal vein here the superior mesenteric artery pulsating here and we work close

on removing all the lymph nodes there here's the main pancreatic vein controlled

with a clip with a ligature you can use clips of course and so we finish

here removing all the lymphatic tissue behind which is between the aorta the

superior mesenteric artery and the portal vein and this leads us to the

previous dissection as you can see here you see the finished dissection

vena cava portal vein superior mesenteric artery and aorta and we finish here the

And in this setting, now I remove this gallbladder on block.

You can remove it separately, of course.

But usually I remove it on block now because I always transect the common bile duct above the junction with the cystic duct.

So I have just one tube for my biliary anastomosis.

And here is the end of the lymph node harvesting on the common bile ducts, before final transsection

of the common bile ducts, removing all the rest of the lymph nodes here, anterior and

right to the common bile ducts.

This is to finish this section, you can see the left renal vein, here is transsection

of the if you don't want any bile to flow you can put a little clamp on the

bile duct I don't care I clean this up I make a faux lavage afterwards and I

just here's the finished dissection extended lymphadenectomy with anatomic

destruction the demonstration of the vascular branches and then sutures

structures and in the end I will show you here the reconstruction we had a

paper on that in 2006 showing 25 cases here's a load of video this is a case i did in 2005

for duodenal cancer in a young man he is alive and disease free after six years now

well it was a duodenal cancer and he had a post-op regimen of five fluorocell like a colon cancer it

It was a glandular adenocarcinoma of the duodema,

so it was a bit different than a ductal adenocarcinoma.

But here you can see the...

Oh, sorry, I had a crush of my keynote.

Sorry, I took two seconds to boot again.

Sorry for that.

So this is the...

I start with the pancreatic or jejunal anastomosis,

usually by pulling the jejunum in its anatomic setting behind the mesentery.

So I retrieve my, like you saw in the previous video,

the jejunum from behind the superior mesenteric artery.

I do a terminal lateral anastomosis on the jejunum,

5 cm from the dead end, using either Maxon 4-0 Maxon or 4-0 Proline.

I would prefer Proline now.

Proline is very handy working with in laparoscopy, making the sutures with a stapler, with a

needle hand holder.

And again, it is difficult, but again, you work close up.

here I the posterior stitches always take the duct so because the duct as you

know that the pancreatic duct is closer to the distal the posterior part of the

pancreas than to the anterior part and so you constructed and interrupted with

interrupted sutures here it was maxon but I used I use more and more proline

now I told you and it's an extra mucosal on the jejunum it's it's if you take

large bites on the pancreas and like in open surgery of course you know that pancreas can be

a bit wider so you have to be very careful knotting those anastomosis those stitches

and it's bringing the the the genome towards the pancreas and not tearing on the pancreas this is

all little tricks that are important of course also in open surgery but it's well it's difficult

but it's in the way. I mean, you can see it very nicely. I mean, you don't need a robot for that.

The robot is only an expensive toy. It doesn't help. It doesn't work on its own. It only does

what you tell it to do. So I feel much more at hand with my regular laparoscopic instruments,

like here a regular fenestrated forceps and a jared needle holder here the I

didn't show you the this is the the biliary anastomosis and of course then

the the gastric anastomosis and here I want to make an important state

statement we don't do laparoscopic surgery for cosmesis you still see many

presentations where the presentator they talk about cosmesis and and so on and

so this is of course it's important because it's what the patient sees but here we are talking

about a deadly cancer and if i do laparoscopy for that it's not for cosmesis it's because i feel i

do a better job than i did open because i'd make an extended lymphadenectomy with minimal trauma

and even the reconstruction of course this is a very demanding operation the resection itself

takes average two to three hours and the reconstructions is also a bit longer

laparoscopically of course taking again two to three hours so it's average

taking four to six hours this was what I took open of course and there are

difficult cases where there's adhesions to the portal vein where you can have

vascular resections to do which take your time I mean one hour more is not

important if you can maybe pretend to cure your patient so cosmesis is

there's something but that's not the end point what is important also about laparoscopic surgery

is you have no adhesions you have less risk of small bowel obstruction which can be life-threatening

and you have less risk also of incisional hernias and for instance this picture of this old

gentleman he didn't care about cospesies but he had a full reverberate with 34 negative nodes he

It was an air-zero resection, and he is alive nearly after three years,

and he's quite happy about that.

So I feel that laparoscopic surgery is okay.

It's been shown to be safe, as safe as open.

I feel I do better than open.

Of course, if there's any problem, you can always, like you say, convert to open surgery.

On occasion, I do the resection for laparoscopic because I feel I have a magnification.

I do a very nice job there, and sometimes to make the reconstruction easier and quicker,

I do a small midline incision, much smaller than I do for a regular open whipple.

And what changed a lot also is neoadjuvant treatment for adenocarcinoma of the pancreas,

enabling to resect more patients in an intention to cure,

and the end point, of course, would be to improve the overall and the five-year survival

of this still very deadly cancer worse than bronchus this is meaning something

so I feel it's the anatomic cancer standard that was my second presentation

When you say that something is better to perform a laparoscopy more than an open surgery, this is a very important message for us.

I think the more you do it, the better you are, but it's the same for open surgery.

Of course, Whipple was the major operation. It's the one we did in the end.

I mean, I started in 2004, maybe, after I did total gastrectomies before that.

I did left spin resection before that.

It was, and usually we, is there, you asked about the learning curve before that.

Like at all times, you cannot, I think an important message, too, is never start pancreas surgery as a laparotomy.

Always, always, I mean, do an exploratory laparoscopy.

Even if you just do the exploratory laparoscopy before you do your laparotomy, because you are at risk of having unsuspected, even with TAP-TDM or TAP-CT, I mean, you have a risk of having unknown occult peritoneal mets.

And it's no use to do a laparotomy for that.

There's always a staging laparoscopy if you have an intention to cure a patient.

Don't do an open and closed laparotomy.

That's a pity, I mean.

Because if you do an exploratory laparoscopy, you see peritoneal mats, you biopsy them, it takes five minutes,

your patient leaves the next day after, and he starts his palliation chemo.

And he doesn't stay in the hospital with a large laparotomy for nothing.

I think this is extremely important.

Yes, and in my opinion...

And if you feel confident, you just start your dissection, you take your time, and any time you can convert to an open.

this is not a challenge this is not a competition I mean I try to do the best

job possible for the patient and has the best better outcome possible so my goal

is zero complication of course this is not possible but doing the best possible

you try to do this yes I'm sure the inspiration and also the ultrasound

ultrasound evaluation are the keys for a successful surgeon.

Yes, but actually the resectability is fully assessed by pre-op work-up.

Now, with endoscopic ultrasound, CT scan and TEP CT, you know if your cancer is resectable or not.

There's no distant mets in the liver, on the lung, and you know if there's vascular encasement or not.

What you will gain extra from exploratory laparoscopy is unsuspected peritoneal mets and maybe sometimes unsuspected capsular liver mets.

It's the same.

Capsular liver mets is peritoneal mets.

Those, if they are large, they will be shown on TAP-CT.

We are working on that.

to assess if tap city shows your peritoneal mets very small ones they will not be seen so

this is the um and laparoscopic ultrasound will do not better than pre-op city yes and in your

experience how many patients can be resettable after the new adjuvant chemotherapy chemotherapy

therapy yeah the figures at this time about maybe one-fourth of the diagnosed

patient will be eventually operated we have more and more cases that get

re-operated after even have a long-term chemo radiation I had a patient who was

considered totally unresectable but after one year of gemcitabine she turned

turned out to be resectable, and we resected her, she was YPT2N0, R0, and at six months

revaluation she developed liver mets, and we still resect, I made a redo frequency,

and so from the final diagnosis she lived two years, which is four-fold what her natural

life expectancy was at the time of diagnosis. So we improve this step by step. This is one of the

most deadly cancers still. Everything is still to do. And well, it's important to select the

patient properly because it's a very complicated surgery. I had one fistula and one post-op death

in about maybe I did 35 cases now so far and of course a fistula is still a problem

okay thank you very much I'm so sorry but time is running and I hope to see you well it's a

pleasure and for me it's always a pleasure to come to Rome I I met Giorgio Palazzini

December 2010 in the Congress in Rome. I was happy for that. So, well, it's nice to make

video conferences, but it's nice to travel and to actually meet the people too. So, take care.