S.WEXNER

Okay. Well, this is the second case. This is a woman who must be, she's 38 years old, and she has symptomatic gallstones. And she has had only one previous surgery for a tubal ligation, not to have kids.

we have the omelikos that we have everted okay and we just place marks in the skin just where

the omelikos goes on its you know when it goes down into itself and we'll just go through the

omelikos okay at this point what we're gonna do is just go in a vertical fashion through the

umbilicus and that's we're going to go through the umbilical stock can you get me uh add some knife

kelly okay s retractor this takes you directly into the abdomen uh let me have a coterie okay

fascia we open the fascia approximately two centimeters in length and everything's within

the omalico so patients won't be able to find their scar afterwards then in this case we're

going to use this uh let me see salesport this is a special type of port that it's flexible

it allows you to place three truckers within the the port itself and it has a tubing system for the

the CO2. And what we do, we just

collapse the bottom like this. We make sure that it's well lubricated.

Good. And then, do you have an Army-Navy? We're going to

place this inside the abdomen as if this would be a

shoe horn. Hold this here. Hold this here.

Clean that for me. Let me have the S-retractor for a sec.

Just a little bit.

okay that's fine okay yes yes thanks perfect let me have the okay so once

again just need to make sure that it's an adequate opening otherwise you're

going to struggle quite a bit there we go it goes in we bring this out we're going to have

those cannula we have another one and this are three small cannula that have a very low profile

and we will keep the heads stuck in such a way that they're at different levels gas please

okay high flow okay yeah that's that's good let me have the camera we're white balance

Okay. Let me have a lap, like a right leg that is clean. Okay. So we have here, that's fine. Can I get head up? And as you can see, I have now three trochars within this port. We're going to leave one in the bottom. And that's going to be the one for the camera. Rotate the table a little bit to the right side of the patient. Left side. Yes, that's right. Okay. So funny gallbladder.

okay and I'm going to start this from this side just to place the switcher

okay drop your hand Bella and just hold the camera there you go

drop your hand now no drop the hand exactly give me a sec okay close this this goes here

put it over here over here scissors okay now let me have uh anything okay ballet you're gonna have

to uh yeah that's fine so i'm gonna go to that other side let me have a that's good let me have

the grasper hold the camera here Bella there you go and with this case we're

gonna use a roticulating grasper okay let me have a kidney I'm gonna ask you

to go in and then you're gonna show me here perfect keep it keep it here this

cope we're gonna have to send it back okay may I get a right angle Bella I'm

I'm going to ask you to get close.

Okay, perfect.

Thank you, Wendy.

Bella, we're going to have to focus or clean or something.

Give me a sec, give me a sec.

I'm going to ask you, Christina, for the hook.

Hold this here.

You may have a kidney there for a sec.

That's perfect.

Excellent.

Back up a little.

Okay, go in.

and we have a sock soaker okay perfect hold it here let me have the hook real quick okay back

up a little ball okay go in at Wendy I'm just gonna ask you to pull a little bit more if you

this here thank you such expert help I have can you give us that roticulating other one sorry

All right, let's bring the camera out.

Clean your camera.

Now, do you have any questions as we're doing this?

Not now.

Okay, clean it really well.

You can hear me.

Yes, we can hear you.

Okay, okay.

And as you can see on this case,

I'm on the other side of the patient.

I'm on the patient where we usually do the gallbladders.

Okay, hold this here.

You had the view not different

from conventional lap coli.

No, that's right.

okay go in get closer exactly let me have that uh right angle real quick actually let me have

struggling with uh with the camera or with my hands because i have a roticulating instrument

instrument that keeps the hands away from each other.

And you hold the reticulating instrument on the opposite side.

That's right. It's coming on the left side of the screen.

Let me have the other reticulating instrument, please.

Now I'm going to have to back up the camera.

Go in. Go in, Bala. Back up.

Clean the camera for the meantime. Let's clean it outside.

side let me have the kidney real quick okay you're battling with me okay perfect hold this camera

okay good okay good perfect hold it here hook actually and christina do we have

back up the camera let's use it okay go in yes keep me in the center back up

Okay, go in. Excellent. Okay. Back up a little. Yes. It's just that whenever we have so many

instruments, you're going to have a little bit of clashing of the instruments. Go in, Bella. Okay,

what we're going to do is this. Give me a sec. Give me a sec. Okay, hold it here. Okay,

Okay, we're going to do this here from this side.

Okay, perfect.

Hold it here.

Move your camera.

So, yeah, you keep me here.

You're going to fight with me a little bit.

Okay, show me over here.

Excellent.

Back up.

That's fine.

That's better, actually.

That's the best one.

Okay.

That's fine.

Back up, Bella.

Hold this here for me.

Okay, stay here.

Perfect, Bella.

Hold it here.

Okay, okay, you have the clip-applier, hold this here, put that in, back up the camera,

back up the camera, just go in, give me a sec.

Do you have a 30-degree scope?

Yes, I have a 30-degree, it's a 30-degree scope.

Now go inside, Bala.

Okay, so that looks good, let me have this, back up, Bala.

Scissors. Go in. Okay. Drop your hand. Let me have a hook. Back up. You're good.

Good.

Go in.

Back up.

Back up, Bala.

Okay.

Go in.

Back up.

Okay.

Release a little bit there.

There you go.

Go in.

Okay.

Pull on your suture, Wendy.

Perfect.

Show me this side, Bala.

Left side of the...

No, no, no.

The other side.

Excellent.

Let me see.

Excellent.

You have a grasper.

Hold this here.

Back up.

Okay.

Show me over here.

Okay.

okay hook sorry hook hook hook that's right and and that's okay that's okay pull with your suture

okay go in bella show me the left side of the perfect keep pulling on your suture wendy

You may come from this side. Good. Hold it here. Good. Yeah. You have the suction. Give

hand, Bella. Perfect. Back up a little. Okay. Go in. Good. Just back up a little. And go

in past the there you go exactly okay back up go in give me a sec okay back up okay go in

and you're pulling is that right wendy you're pulling is that right yeah back up

okay give me a sec okay we're just about to finish but most times this is the most annoying part

Tell me if you agree. It seems to me that the biggest drawback, the closer you get with

the optics, the less freedom you have with the instruments because they conflict.

Exactly. Okay.

Back up the camera. Especially when you have more than two instruments. When you have only

two instruments, you can get by by doing most of these things without problems.

Did you try any of the angling scope, like the new Olympus?

Yes.

Did you have any advantage?

Yeah, I have used that in only two cases because, as I have said,

it increases the capital expense for my operating room

in at least 20,000 to 30,000 extra euros.

But you can use it.

The only other thing, can I have, let me see.

I'm going to switch now one of those five cannulas to a 10

so I can use that endo-catch.

Let me have the camera.

And the other problem with that instrument,

I mean, you can use that endoscope.

It's very good.

But it has a little bit of a learning curve,

so your camera driver may need to be much better.

Yes, that's right.

Okay.

Can you give a scissors to Wendy? Dr. White? Yes, go ahead. Can you flatten the table for us? Hold the camera, Bella. Okay. And I'm going to switch this to a 5 again. And the benefit of using this stroker is that I'm not going to have a leak after removing the 10 and putting a 5, which is very good. It's very versatile.

versatile, I just want to go back in the abdomen and make sure that everything's okay and then

pull the specimen out through this.

Now, do you have any questions as we do this?

No.

What was the first time when you used this stroker?

Because here in Italy, they're presenting it to you, I think, next week.

Yes.

Okay.

We used it maybe, what, three months ago?

Three months.

I would say about three months ago.

actually it was in January yes and it was just as part of the clinical testing

evaluation for for the company who makes it which is Covidien and they just

released this for commercial for available use for everyone maybe three

four weeks ago at Sages and it's a I think it's a very convenient device

whenever you do something really advanced certainly for the gallbladder

It made it look really easy because it really allows it to, you know, you can use more than one instrument besides a camera.

I don't know.

It's a neat device.

Now, before we finish the case, I feel very fortunate today because I had with me La Profesora White, Wendy White, and she's one of my partners.

And there you see.

She's a professor?

Yes, she's a professor here at the university.

She's the most sophisticated professor I know, most fashionable one.

She deserves to be in Milano.

Uh-huh.

Okay, yes.

Let me have a grasp here.

Now, this incision is going to be inside the...

Is she Italian?

Cristina?

Cristina is here, too.

Yes, and Cristina, she's my scrub tech.

And she works with me for all these cases here.

Hold this here.

Is she Italian?

Her mother has ancestry from Italy, so half Italian, yes.

Do you have a micro?

We have a very multicultural team.

I'm from Mexico myself.

So, yo parlo espanol molto bene.

We have another co-worker.

Let me see what I think.

I think you did it safe without any major risk for the patient.

I think the major risk is your sweating.

That's right.

I think you really have to have good exposure, adequate exposure of this.

Otherwise, it's not safe.

Actually, what I'm going to do is just go from the bottom, from here where I can see it.

Excellent.

And I would say the most difficult part of the operation is to close this.

It's closing the umbilicus.

Also, you have to close it well, otherwise people worry about hernias afterwards.

Unfortunately, we see a shoulder.

Okay, now you can see it.

Yes, that's fine.

And I just put a running suture of something absorbable like Vicryl or PDS.

Now, I don't really know if there's any benefit as far as pain post-operatively.

I know the main advantage of doing this without any doubts

is that patients will not have any scar that they can see.

Now, the thinner the patients are, the more difficult it is

to actually hide that scar but but you can thank you that's right we're talking about incision on

the hernia did you have any yes yes that's one of the concerns that people have I haven't had

one but I think you need long-term data for that okay now as I mentioned in the case in the previous

case, when you use only two trochars, a lot of the times you end up having to

make the incision bigger just to remove the specimen as you would do otherwise

with a gallbladder. So it should be theoretically the same risk of

herniation as with a conventional case, but we don't know. Now we're going to be

be involved in a prospective randomized trial on doing LAP-COLI versus SILS-COLI, and that

it's actually on its way. I think Professor Tacchino from Italy, from Rome, is one of

the investigators. Yes.

And we are another investigator as well. I think I saw you doing one of these procedures

do without this type of stroker I think in November exact yes no October and

November okay yeah you can do it without and if you think about it before this

was available we were doing this and we just didn't have it but it's a it's a

discharge a patient take a look yes uh in just a couple of hours maybe once they're uh you know

fully awake we give them a little bit to eat and they go they go home and we do the same with a

regular cholecystectomies so it's not nothing different now if you can see uh or is this

that's going to be inside the omelikos let me have just uh whatever you have

Sure, let me add some marking.

Now any other comments or questions?

No, I don't think so.

Okay, you did see the pictures of patients coming back to the clinic

two, three weeks after surgery,

and the aesthetic results are very impressive.

Now as I said, pain, I'm not sure if there's like a huge benefit on this because...

Cosmetic results.

some patients yeah some patients do complain of less pain but some other patients complain of

just as much now with laparoscopic cystectomy they have very little pain what kind of suture is this

going to have a scar slightly bigger than the other one that otherwise with two trockers

but uh it's gonna give you more freedom to do more things because you have an extra hand

um so that's that's just it i mean what should we do just yeah yeah we'll just do a few

i never close this myself so it's the residents who close it

do you have any experience in the states with notes natural or if it's laparoscopic no yeah

no in in the u.s we don't have any here at this institution because of uh you know some ethical

things and we don't have an ethical committee that has approved us to do that we have a lot

of experience with animals but that's not any good i told you about my experience with 14 hybrid

cases but that's in Mexico but after having done all of this I just I think

this this makes a lot of sense it's easier safer patients accepted you can

do it in your operating room with all the technology you have with all the

knowledge that you have your skills etc and the other one is going to be much

more difficult to implement at least for a while I'm sure at some point perhaps

Perhaps we'll be able to do that, but I don't know yet.

And after all, amblychis is a natural orifice.

That's right.

And the other thing is, like, lots of people who are doing notes clinically,

they utilize more than one additional port, and still they call it notes.

You know, some people may call it assisted notes, hybrid notes, et cetera.

But this is that additional port that you're putting.

I mean and you don't have to go through the rectum or vagina or whatever now

today we have four of this gallbladders so we have two more but those we're

gonna keep it to ourselves but that's just so you have an example how how many

of this you can actually do now most people when they do notes they may do

one a month in a week if anything yeah but this is like excuse me what time is it in dallas

yeah what time it is uh 10 15 in the morning huh and you did two yes is that uh too slow or

no at all not at all we usually it's very fast we usually good good we usually do uh

courses where we bring surgeons and they see three gallbladders and you know

before noon before 12 so we're very efficient at doing that thank you thank

you that's Emilia but also that white thank you Bella thank you

congratulations next time you're welcome next time we'll go to Italy and we'll do

it there okay sure okay congratulations again grazie mille grazie mille a più tardi goodbye

bye