Qu\ Tu Sigmoid colon cancer with hepatic metastasis laparoscopic surgery

我们这边准备好了,可以开始的话,就请意大利主持人先开场

Professor Chu, good morning, can you hear me?

许院长,您好,可以听到我的声音吗?

Is it better?

Yes, we can hear you.

Is the sound clear now?

It's okay.

I think that is because you're wearing a mask, but it's okay.

Ah, okay, I'll drop it then.

Okay, thank you.

Okay, Professor Chu, good morning from Rome.

I send my greetings and regards from Professor Palazzini on his behalf.

Thanks for partaking to this important meeting, the 32nd edition.

So I hope you enjoy your participation and we wish you a good operation.

I'm going to enjoy your op. Thanks very much.

Distinguished Chairman, friends in GI surgery, ladies and gentlemen, good morning.

Good morning. Good morning to you again.

What are you going to present?

I'm very delighted that we can gather here to witness the opening of this year's GI surgery Congress

to exchange our experience with colleagues from across the world.

Zhang Jiagang is in the east part of China, we are 150 kilometers away from Shanghai, 80 kilometers away from Suzhou, and 12,000 kilometers away from Rome.

First of all, on behalf of Zhangjiagang First People's Hospital,

I'd like to congratulate on the opening of the conference

and to say thank you for providing us with this platform for exchange.

Founded in 1962, our hospital is a Grade A tertiary general hospital.

We have a total construction area of 204,000 square meters, 1,682 registered beds.

68% of the surgeries we perform are Level 3 and Level 4 surgeries.

We have more than 2,200 employees,

among which 360 have doctorate or master's degrees,

1 is doctorate supervisor and 10 are master's supervisors.

8 have full professorship or part-time professorship.

We have 6 research and innovation teams, successfully started 11 projects funded by National Natural Science Foundation in the past 4 years.

The department has successfully performed a variety of minimally invasive surgeries,

For example, laparoscopic pancreatic duodenectomy, laparoscopic radical surgery for gastric cancer, colorectal cancer, and laparoscopic hepatic lobectomy or segmentectomy and mycolysis thyroid surgery, etc.

Now let me briefly introduce today's surgery team.

They are Vice President Sha Weiping in the management group,

and Professor Tu Jiancheng, Associate Professor Fang Jian,

and Junior Attending Zhang Chao in the operation group,

and Professor Daoyan Ping in the anesthesiology group,

and the nursing team led by Deputy Director

Gu Ronghua in the nursing group.

And also with us are the specialists

who took part in the previous MDT sessions.

Thank you and wish this year's conference

a great success.

Now I will hand it over to the operating surgeon

to present the case professor to Jiancheng.

First of all, I would like to thank everyone

everyone for this opportunity that you have given to me.

Respected professors, dear attendees online, greetings.

Our patient for our demonstration today

is Mr. Li, 68-year-old, came to our department

in July of this year with chief complaints of bloody stools

for about one month.

The colonoscopic

Scopic examination revealed a lesion about 25 centimeters from the anal verge.

病理检查提示有癌病。

Pathology examination of the biopsy showed cancerous adenomatous cells with high level of differentiation.

免疫走化结果提示微微性稳定性。

Immunohistochemical analysis showed stable microsatellite.

在7月15号的持共症检查当中发现有6个转移病状。

On the 15th of July, an MRI was done, showing six metastatic hepatic lesions.

The preliminary diagnosis was synovic carcinoma with metastatic deposits.

第一次MDT以后,决定行书前的转化治疗。

From the 28th of July to the 25th of September,

four cycles of neoadjuvant chemotherapeutic regimen of Acetuzimab with Folfox were administered.

Our second MDT concluded the next step of therapy

is to simultaneous excision of the malignant lesion

in the sigmoid colon

as well as the ablation of the metastatic deposits in the liver

thereby achieving an NED status.

Our surgical operative is laparoscopic approach

to excise the primary lesion in the sigmoid colon

and radiofrequency ablation of the metastatic deposit in the liver.

Thank you for your attention.

Thanks, thanks very much.

We're waiting for your operation.

so as to identify the blood vessels during our procedure.

Okay, now it's far better.

Now you can see it clearly.

We use the five-hole technique.

This patient has liver and liver disease at the same time.

Do you think it's more reasonable to treat liver first or liver first?

Professor, I have a question for you.

Our patient has two lesions. One is in the sigmoid colon and with metastatic lesions in the liver.

So I would like your advice in the course of my operation.

What would you think is the better course of action to first excise the primary lesion in the sigmoid colon

and then excise the metastatic lesion or the other way around?

Hello, Professor. Can you hear me? Can you hear us? We can't hear you. Yes? Hello?

uh say can you hear me if you can give me a thumb up um hello hello can you hear me

we have a question for you that is we have a hepatic illusion that is a metastasis and another

is uh in the sigmoid colon so which to excise first so can you hear me professor hello can you

about the terrible metastatic liver deposits of colorectal cancer.

What are the factors to consider to choose simultaneous excision

or phase excision of metastatic lesions?

That was my question.

So from the right peritoneum, we start the cutting, the dissection.

Yes.

And we take a medial to lateral approach.

Can you please repeat, Professor? We couldn't hear you well.

Right. How far do you go with your dissection up to the splenic flexure, or is it not necessary?

Yes, professor.

As we proceed with our dissection,

we may dissect till the splenic fracture.

So this is the layers of the toe scar.

It is very common during my practice to find variations of the inferior mesenteric artery.

Yes.

We try our best to preserve the main colon arteries.

The camera has some irregularities, so we will just clear it up with some hot water.

We keep our pneumoperitoneum at 12 mmHg.

Here with my left hand, I use the coterie with the clippers.

And with my right hand, I try to aspirate through my operation field to reveal the artery

Here, I can find a very thick artery.

artery, because I can find there is some variation, so to reveal the artery as clear as I can.

Professor Chu, up to which level do you go to the inferior mesenteric artery from the

aorta?

A couple of centimeters, less?

Also considering the endovagal variations of the arteries?

Sorry, we can't really hear you.

Can you repeat your question?

It's not very clear, your voice.

I'm sorry for that.

In fact, the sound is not so good, even this side.

I was asking, up to what level do you go

to expose the inferior mesenteric artery

in distance from its origin, from the ulcer?

就是问我们在处理这个长性膜下动脉的时候

这个步骤,因为是从它的这个根部开始游离

然后还是什么样?

我们从根部开始游离

We start to free it from the root.

That's the step we take.

Okay, thanks.

Here, this artery may be a tributary of the left colic artery, so here also I'm clipping

and ligating and separating the vessel.

So I'm seeking the help of my first assistant to tent the mis-entry so that I can further

we encounter the

tolls gap

first assistant

so that I can further

move on

with my dissections

excuse me

just another question

do you routinely

use the ink

green and the cyanine

for the

to recognize that it's a good vascularization.

杜主任,我们手术的时候

我们会不会经常用美兰?

比较少见用,很少用。

今天因为Colibus要转播,要节省时间,

所以我们手术中没有做场景检查。

I do not usually use the dye during my surgery.

Especially today, I decided to use the dye for the streaming,

considering the online attendees to clearly see the vessels during my surgery.

It aims to save some more time, but we don't usually use the methylene glue.

we can appreciate the avascular planes retroperitoneally.

We're going to identify the left urethra.

We still cannot appreciate the left ureter for now.

But as I go further with my dissection,

we will be able to appreciate the left ureter.

But usually we don't have to really show this left ureter.

So we checked with the pneumo-peritoneum

and now we will maximize it to 50, increase the pressure to 50.

Yes, the pneumo-peritoneum will also help you in the dissection.

We were doing it with 20, now it's 45.

Here, I'm almost done with my dissection at this point

because as per the colonoscopy examination,

the lesion is about 25 centimeters from the anal verge.

So at this point, it is enough for my dissection.

现在我们从外侧,这个地方有少许链链,可能还会有扇,这里有一个紫扇的扇。

At this point, there is a little spot for 和鸟。

紫扇的周围有少许链链。

And there is some tiny minor adherent here.

If I can recall, on your presentation, this patient didn't have any previous laboratory, isn't it?

but the lesions are still there.

This patient hasn't had any surgery before.

So the adhesions that we see, they're all physiological.

Here I continue with my dissection

to mobilize the sigmoid colon.

Clearing up literally all the attachment to the lateral pelvic wall.

So the professor is asking,

is the video clear enough for you to see every detail?

Is the video clear for you to see everything?

It's a question.

Yes, absolutely.

Although sometimes the optic becomes a little bit foggy,

but now it's clear.

Now it's clear, very clear.

现在非常的清楚,我这边视频的传输是没有问题的,但是偶尔可能我们的镜头连起雾。

So just one very thinly of connective tissue, so I proceed even more carefully.

正确要朝上,翻到齐全。

In this case, maybe I will have to clear up the colon till the splenic fracture.

But as I proceed with my dissection, I will decide.

So I place the goals here to fix the position

so that literally when I'm dissecting, I know which position I need to go.

how deep I should go on with my dissection.

After clearing the very thin layer of connective tissue,

the gauze that I placed medially will just come through as I proceed laterally.

I can see that the position of the patient is tilted toward the right-hand side,

which helps a lot.

But also, I must compliment you, how young is your team?

I can see that your shabu is used to locate the patient.

I can see that very clearly.

And I also want to say that your team is really very young.

Thank you, professor.

Thank you.

As in these days, with the primary colorectal lesion and metastatic liver lesion,

This place is where I will clear up around.

This is the resection line that I will proceed with, inferior to the tuba.

Here I'm asking my assistant to pull up the sigmoid colon

so that I can clear up around the mesentery, around the colon,

preparing for the resection.

Okay, this is the place where we will be resecting the colon.

Do you do any bowel preparation? Is that necessary or not?

Yes, that's part of our routine, our clinical pathway.

We will prepare the bowel before we do the procedure.

Especially for the left colon and the rectum.

As we continue to clear up the mis-entry of the connective tissue around the colon,

inferiorly, I come across an artery.

Most probably, it's the sigmoid artery that I need to ligate.

to continue clearing up the connective tissue around the sigmoid colon.

The mesocolon looks quite thick and edematous.

This place feels very thick.

The swelling is also quite severe.

Yes.

The scene was set up in the morning, a bit earlier.

It was set up six hours ago, a bit earlier.

So we did the colonoscopy about six hours ago to identify the lesion.

So it's a little bit too long ago, six hours too much.

Actually, we seldom take this approach.

And usually we do it during the operation.

Oh, here I'm correcting the mis-entry.

retro the mesentery around the colon so that when I proceed further with the next step to do the

extracorporeal anastomosis it will be much easier with a less of the connective tissue around the

colon. Here I come across a blood vessel which I will be ligating. The ligating clips I use is

a hemlock. With the help of my first assistant, still tenting the mis-entry, I proceed further

with correcting the extra connective tissue around the sigmoid colon. Actually, it's just

part of the sigmoid colon, so still correcting around the excessive connective tissue. Here,

I come across another blood vessel, so clearing up around the blood vessel and ligating.

So I'm almost

Reached

The part of demarcation

Where I will be

Putting

Proceeding with anastomosis

This is the place where

Extracorporeally I will be

Setting up the anvil

Okay, the next step is to make a small incision on the abdomen and to proceed further with

the extracorporeal anastomosis,

transecting the sigmoid colon

where the lesion is,

placing the anvil.

This is the demarcation point.

I use a ligating clip here.

This is the place where I will be placing the anvil.

So here, literally, I will be furthering my dissection to free the colon here,

mobilizing the descending colon.

Here we can appreciate the left urethra and the grenade of arteries.

So here there is no damage to the artery and to the vessels.

前面是从肾前筋膜一直延续到盆底的。

这里有点出血,我们来指一指。

Here we can find that there is a little hemorrhage,

so we have to take care of that.

I'm still using the cotri here to take care of the hemorrhage site.

With my left hand, cotri cauterize the hemorrhage site

and with my right hand, aspirating in excess fluid.

I'm still very careful here because this is the place where there are staples.

Pretty satisfactory result with hemostatic.

This is the place where I just took care of the adhesions.

Okay, the next step is to find the piece of gauze that I placed before.

to retrieve the specimen.

retracting using the thyroid retractors,

I further proceed with the incision,

very carefully separating layer by layer

to the abdomen.

Can we use the retractor?

Here I use the automatic purse string suture clipper instrument.

Placement of the anvil here and securing the anvil with a purse string suture.

I make sure that my assistant ties the knot tight enough so that the anvil doesn't slip.

So I make sure that there is no excessive connective tissue that will hinder the anastomosis.

Tearing up here also the excessive connective tissues for a better anastomosis.

So the next step we will go intra-abdominally again laparoscopically to do the anastomosis.

So, we check out here the orientation of the colon here.

Any excessive blood vessels in the mesentery during the dissection, we still need further

correction.

But here the dissection seems pretty satisfactory, no evidence of any excessive heating of blood

vessels or any hemorrhage.

So, I adjust the orientation of the colon here.

This is the anterior mesenteric at the site of ligation and separation.

This is the left colic artery.

The single artery is here.

As per my experience, the first side of the mis-entry

checking the colon for any tension, for tension-free anastomosis,

because, okay, it's very clear and it's very perfect for me.

Sorry?

She said it's very clear.

It's very clear, you can see it here.

Ask a question, ask the young man.

Ask a question.

Ask them a question.

What question did you just ask?

The first one, is it the same or different?

They didn't answer.

He didn't answer.

Do we need to ask one more time?

Let's talk to him first.

Okay, this is the part where our excision of the primary lesion in the sigmoid colon is done

and completed with the anastomosis.

So the next step, I will be proceeding with the ablation of the metastatic hepatic lesions.

So, hello, Professor. I think you mentioned a question about simultaneous excision or phase excision and the steps preference. So, I think Professor Tu will respond to that in a minute, and then we can, of course, discuss it.

Yeah, thanks very much. Thanks.

So it depends on the patient's conditions.

If the patient is well enough,

then our first choice will be simultaneous excision.

That is the plan A, if the patient's conditions allows it.

So what's your opinion, Professor?

Because we are gastroenterologists,

so we tend to do gastroenterology first,

and then treat the liver.

And as we are GI surgeons,

so we usually deal with the GI problem first,

then move on to the liver.

So what about you?

Yeah, what is your preference?

No, no, no, I agree 100%.

Also, being a gastroenterologist and a surgeon,

I would do exactly the same.

Also, depending, as you correctly said,

on the comorbidity in case and the fitness of the patient.

我也同意您的观点

在我们这个中心也是这样来做

而且就像您说的

主要要看患者的身体状态

So here we are done with excision of the primary lesion in the sigmoid colon

And with the help of my assistant

We are just setting up a drainage tube

Our next step in our procedure

Will be dealing with metastatic hepatic lesions

So, still proceeding with a laparoscopic approach.

One more question.

Is there any reason in case to deal with repelitonization?

Sorry, what is your question?

Hello, Professor.

Yes, I'm here.

Is there any place deep down there to close the anastomosis?

No, no, not the anastomosis.

To put the peritoneum around.

Ah, ah, ah.

This patient pre-operatively, pre-chemotherapy had six,

we counted six

hepatic metastatic lesions.

And post chemotherapy,

we significantly noticed

the reduction of both

the primary and the metastatic lesions,

so much so that

But five of the metastatic lesions reduced significantly, and we cannot find them now.

So here, we will proceed with ablation using a radio frequency of one of the single metastatic lesions that is left.

Here, we can find that there is a demarcation that we did preoperatively.

Because pre-chemotherapy, there were six lesions in all, and five of them reduced significantly.

So for the better recovery of the patient, we still proceed laparoscopically.

So this is a radiofrequency ablation probe that we can see.

how long do you usually do it

say 10 minutes, 15 minutes

what's your range

can you hear us

yes I do

well from the literature

what I can extrapolate is

10 minutes

not my own experience

10 minutes I would say

usually it's 10 minutes

if they do the face-to-face

So we can see that after several minutes of radioablation,

there is a change in the structure of the liver tissue.

So we can see that there is very clear change in the structure of the liver tissue

So for the radio frequency ablation, we use the microwave ablation.

So what about you?

Do you have any experience or comments to share concerning radio frequency ablation?

No, not myself personally experience in this

But I believe that is the correct way

But I myself don't have experience

Thank you

I am very careful taking out the needle

because of the very high temperature of the needle point.

Hello, moderator. Hello, professor.

Yes, you can hear and see very well.

The excellent procedure.

Yes, I think,

我感觉这个手术还是做得很成功的。

Professor T will give us a short summary of the surgery.

发挥主席。

Okay, thanks very much.

手术基本结束。

今天做了一个胰状结肠的根治。

整个手术过程是出血不多,

但是在左结场血管的地方有点变异。

这个变异的话是左结场血管

so that the lesion could be much clearer during the operation not only for us but

for our online viewers and for for all the viewers online and the next step

after the excision of the primary lesion is to after the anastomosis of the

sigmoid at the sigmoid colon we went for a laparoscopic radio ablation of the hepatic

liver hepatic metastatic lesion which i believe is satisfactorily successful

and i can say with quite some confidence that our procedure today

has a little bit of variations that we corrected during the surgery.

So that is very good.

But the only less satisfactory thing is that the methyl or blue

before the operation doesn't really work that well.

But for the rest part of it, for the liver ablation,

I think it all goes well.

Yes.

In fact, I must congratulate Professor Chu and, of course, his team

the radio frequency ablation, which is again, nice to see.

You must congratulate you and thank you from all of us

and especially from Professor Palazzini,

was really a very nice, enjoyable operation.

Thanks very much, Professor Chu, thanks a lot.

Would you hear me?

Could you hear me?

Hello?

I can't hear anymore.

Hello?

non si è più sentito nulla.

L'operazione stavo ringraziando,

volevo parlare ancora.

Ah, hanno sentito,

perché io non ho più ritorno.

Ah, ok.

I was translating your comments.

Ok, all right.

And your congratulations.

So now I think President Qu

will give a closing remark.

President Qu,

please read this.

Good morning, Chairman.

Just now,

our gastroenterology

So Professor Tu Jiancheng has just completed a case of laparoscopic sigmoid colectomy

plus liver metastasis radiofrequency ablation. Let's say thank you to all the medical staff.

同时也感谢大家两个多小时的在线观看,聆听,指导,期待下一次与大家面对面的交流,一起探讨,共同进步。

And thank you all for following us online in the past two hours. I look forward to face-to-face exchanges in the future.

最后,祝各位专家教授身体健康,工作顺利,万事如意。

谢谢大家,谢谢主席。

And at last, I'd like to say wish you all good health.

Thank you, thank you very much.

Thank you, Professor.

Okay, Prof.

Thanks very much for your greetings, for your wish.

And we also worldwide hope really the same.

And we hope to have you one day here in Rome.

也非常感谢各位的精彩展示,

也非常感谢您的住院。

我们也期待着线下的交流和更多的合作和共同进步。

谢谢。

Bye-bye.

Bye-bye. Thanks again. Bye-bye.