TANG robot- assisted laparoscopic cholecystectomy + exploration of CBD

You can begin.

Oh, I can begin. Okay, that's good.

That's good.

That's good. Okay.

Good morning.

This is CN10 from

Hong Kong.

And I'm very glad to participate

in this virtual congress.

Italian

Digestive Congress.

And I would like to show you a live

surgery conducted in

Hong Kong. And before I

start doing the surgery, I would like to

introduce the patient I'm going to operate on, a female patient, 75 years old, who had

past history of diabetes, hypertension, Parkinsonism, received multiple abdominal surgery, including

surgery for CA rectum, for recurrent CA rectum, and also closure of transverse colostomy,

and also on one location requiring laparotomy for intestinal obstruction back in 2015.

She presented with acute cholangitis, barycepsis, septic shock about one month ago

and presented with cholangitis.

At that time, we arranged an imaging study showing a stone, a widow pig stone in the

common dioduct causing dilatation.

We performed emergency LCP, confirmed presence of two centimeter common dioduct stone with

a past extent inserted.

Next.

So, I hope you would allow me to do a live surgery,

robot assist laparoscopic cholecystotomy,

and exploration of common bile duct.

Is that clear for the patient history?

Repeat the question.

Is it clear?

I mean, regarding the history of the patient?

Yes, yes.

Perfect.

Let me just go to the back side.

I think largely I use the second arm for the camera and the first arm here and the

third arm as the working part and this is the last one the fourth arm as a

retraction part yes okay of course robotic surgery is not a surgery done by

robot alone I mean we have to get a team and doing the whole operation I got

Not only that, I've got a well-experienced corporates helping me at the back side,

and they are helping me while I'm working in the console.

I think that would be the layout.

It's not actually a reverse,

a snake reverse transition position,

and ducking from the dome and so and so.

Any questions regarding the operating table layout and so and so?

Why?

Any questions?

I want to do a question. Why do you choose the robotic way and not an open way? Because there are a lot of additions, I think.

Oh, yes, I see your point, but the previous operation are largely peri-embolic and also lower abdomen.

I mean, if you talk about the surgery today, what I'm going to perform is not just the upper part of the abdomen,

and there's no major incision in that area.

I think if we can perform it in minimal invasive way and patient could recover faster.

And if there will be multiple scar, upper, lower, and here and there,

I think I would think about doing open surgery.

But this is still optimal for robot surgery because the upper domain is free of any surgical scar.

Okay.

Okay.

Okay.

Let me just.

okay let me just go back and the console and uh think about i i will try to describe what i'm

doing when i uh working at the console if you've got questions by all means phone me the questions

and i might be a bit late in answering the question but this is still fine okay okay let

me just start the surgery i don't know whether you can see the um the console well uh the

There is also a specimen bag, once after I finish everything, I put it inside, and then

get it out at the end of surgery.

I think this is the initial preparation.

Okay, let me just start doing the surgery.

Before starting the surgery, I think, get a look, I guess, this is the duodenum.

This is the duodenum.

And this is the gallbladder, I guess.

and I need a bit of further dissection before I can say for sure whether what

this is rather common for reoperative surgery. I mean, very often there will be

quite dense adhesion here and there. So define clearly about what you are tackling

of repeated infections. ARCP, usually I find some adhesion when I operate after the ARCP with the

stent. Do you know? Yes, sure. I think that that's also quite common. Apart from ARCP related adhesion,

Yes. This is a diodenum and this is the falciform here. I think the landmark is

pretty clear. Now I will dissect further. See how the third arm is helping. We

basically using the third arm as the retraction, as the retraction, okay? Okay.

Now it's more clear. We see the separation of the gallbladder from diodenum.

see yes some adhesion yes some adhesion yes inflammatory adhesion the picture is good

very good very good i'm so glad you're happy with the picture because i think if you cannot

see a very good picture and even you've got wonderful surgery this is still a bit suboptimal

i will take down a bit of precision around this area so that i can have more working space

For this area, I would try to pack the gauze around this area because whenever I cut open the boulder, there would be boulders leaking out.

It would be collected in Morrison pouch.

So get the gauze around this area to avoid the contamination of the peritoneal cavity.

So this is so scarred here.

This is so scarred here.

In the left side of the gallbladder.

We might have to wait a little bit longer.

Let me just adjust a bit the image.

Yes, image.

This is a bit better.

I think this is the build-up.

Yes.

Okay, let's move on.

Let's move on.

Give me the ultrasound.

The robot one.

How can it be so good?

Okay.

i think this is the bound up this is this area you are expecting to see the junction between

go better and the common powder and this is the very contracted operator here i think i'm not i'm

not doing with that global right now i would i would think about exploration of common build up

define a bit here before i move on to excise the ball better okay um

Let me just show you the intraoperative ultrasound, apart from 5-5, and to demonstrate how it

looks like on the ultrasound, or something.

So the anatomy is pretty clear now, stomach, pylorus, duodenum, bowed up, and very contracted

gallbladder.

Now I'm waiting for the robotic ultrasound and show you.

I think even without ultrasound, you can tell quite well.

Passing down, there's a big stone here.

But I would like to show you a wonderful image.

How it looks like on ultrasound, okay?

有咩?有咩呀?

入咗嚟先嗰個ultrasound。

有咩?有咩話俾我聽?

Huh? No. 咁都老得。

有咩?你轉咗去endoscopy呀.

P&P.

Okay.

Now,

出多少数?

Okay, 是。

大一点, 抹大一点。

抹大一点。

Medify.

I think, 大一点, 大一点。

Okay, I think you can see a big stone.

Can you see it?

On ultrasound?

A very big stone inside the common biotech?

Do you agree?

I think this is the stone.

有没有connect的现在?

没有声音的。

Okay, I think next step,

走。

I would do the corticotomy here to extract the stones.

Divert me.

冇聲嘅點解?

佢哋冇咗嘅,開始。

唔係,我知,佢哋好似冇咗聲嘅。

Are you with me?

Are you with me?

係咪connect緊嘅?

Any comment?

Any comment so far?

係咪斷咗呀?

我都問佢囉。

Any comment?

Any questions?

我知,我而家問都問到冇反應啦。

畫面不停都是他那條宣傳片的人。

不要,不要,我看看先。

沙沙力,沖一沖水,上高,沖一沖,OK,行。

下面,那條cafeter,那條cafeter,cafeter,

河河,Are you with me? Are you with me?

開咩開左未開燈

人多數別冇開到燈呀

真係離曬大埔呀

冇開燈冇開燈

交交

上工

上工

停水停水

停水

睇上工

OK呀

因為落

不用

上工冇嘢

走走

熄水

掛番比我

比番個 instrument

搞掂未呀

知唔知點解聲有問題呀

我常試whatsapp緊佢個tag呀

但係佢未熟呀

Now I'm going to excise the gallbladder

and then follow by repair of the colicoscopy,

colicotomy.

Now I'm going to excise the gallbladder.

I think this is a very chronically inflamed gallbladder.

Let me just, I'm so sorry, there's a bit of a noise issue.

Let me just do a one-line commentary while I'm doing the operation.

Because this is the area you're expecting to see the common boulder.

Okay, I think this is the area you have to pay extra portions.

Even if you're perfect, the gold boulder doesn't matter.

But what seems to be extremely important, don't injure the common boulder.

Okay, it's not a very friendly gold boulder.

Now I'm going to excise it with a very careful way.

I hope you are still able to see what I'm doing.

佢聽得清楚嘅,聽我哋嘅。

Okay, good, good, that's good.

Okay, it seems that there's something here,

but I'm not sure, but I will further dissect,

see whether I, I may just cut it,

and then fish out all the stone,

and shoot you back, just in case.

Clean up the hook, okay?

That's good, you are still able to listen to my voice.

Now, I almost finished the surgery, I have done the ECBD exposure of the common biotope.

Now I'm moving to excise the gallbladder.

thing it looks like there's a level ring in this area but there's also another pouch in the system

area and now i can see when i move down a bit able to see a hole this is probably connected to the

cystic duct so this is the area i would expect to see the connection of the goblet and also

common powder and this is the uh area i guess this is diamond pouch there's a bit of outgrass

appearance uh slightly higher so this is still uh common powder okay i think this is the uh

translate a little bit further in case i can see stones in the stomach so because there's

no cure anatomy in this area i think it is still safe right now whatever we started quickly

transferred to the back i will prolong contamination with the abdominal cavity and then i would do a

bit of hemostasis i see something i see a uh i see a pouch i see a pouch here okay there's

thing inside can you see it i might have to reset a bit more this is probably still the uh system

look at here this is the pouch still connected okay so my next step would be to see whether

there's anything i think this is still the system area okay the only worry what i've got this is not

I would expect without T-tube, without stand,

patient could recover faster, okay?

I hope the voice can come back soon,

but I'm still describing what I'm doing.

Hope you can hear well with monocle, sound more.

Okay, good.

Okay, this is the C-sit-duck.

I think when you talk about suturing,

robot is the best.

when you pick tissue.

Okay, let's move on to close the common bile duct.

prefer to put in something like T-tube.

But I guess the evidence right now is good enough to support there's no routine T-tube because T-tube simply gives you a lot of drawbacks in terms of complication, in terms of delaying the recovery time and so and so.

So, particularly for minimally invasive surgery.

I mean, about 1cm, 1.2cm.

I rather prefer to post it in an interrupted manner

because continuous posture is associated with higher sexual weight.

That's why my personal experience suggests it would be a bit safer to think about interuptive closure.

But if you talk about a very huge sheet I did come and build up, say for example 2cm in size and so and so,

you probably don't need interuptive closure. Clean up the lens.

I hope the surgery is not too boring

because it's a bit simple

initially I plan to do a different resection

but case is not available

so I choose another one

I hope this is still good enough

for the purpose of light demonstration

look at this

this is how we are doing

needle cutter

you can use it

as a needle holder

you can also use it

as a scissor

because there's a life

at the proximal end

of the instruments

this is needle cutter

I think this is

a very good instrument

I still have

5-10 minutes to go

and I hope we can

reconnect it once again

with this song

and so much so that

we can have a bit of

discussion if possible

new structure

ok

特醫生,我打了給他們,他們說應該解決不到那條聲。

我不敢要了,不敢要了。

你照講,他聽到,他說你1UP了,就OK了。

OK,OK,OK.

麻煩你了。

I'm so sorry, I think the voice issue cannot be settled by the time I finish the operation.

I think I will just carry on and tell you what I'm going to do.

I think I will just continuously closing it.

and this is the last closure this is the last closure I would I would live a

dream around that area for one or two days if there's no power leak and then I

would I would be full faith I would also monitor the different function

post-operatively to see whether there's any abnormality even though I check

everything with the colitoscopy and there's no residual stone inside but you

you have to prove beyond doubt.

And let's see whether I got anything here.

不如比個舊新嘅歌聲,

比個Progressing,

Progressing.

So, I want to check once again the closure,

whether this is intact or not intact.

要呀,我帶我入手袋先,

入曬袋先,

入曬袋先,

我唔想呢啲咁污糟喺度。

OK, I put everything inside,

and then I close the bag,

同我打少少水就冇了。

我睇睇先。

OK, I put at the subthinic area.

OK, and then suck here.

打打水沙塞。

OK,打打水沙塞。

I would like to add one more here.

OK, 沖一沖這裡。

沖一沖這裡。

It's too bright.

俾多針我。

I think the culture here is OK.

The culture here is OK.

I think I would add one more here.

依度度。

I'm sorry

I finished the search a bit

earlier than

my original schedule

I want to show you in two hours

but now it's just

not even an hour

I would like to add one more here

whether the kosher is

secure or not

I think it is okay

what do you think?

one more and that's it

that's the last stitch

I will leave a jing in that area and leave it for one or two days before I pull it out

because there's still a remote chance, even though at the moment there's nothing, but

you might have a bit of issue.

I hope you are satisfied with the culture, the surgery, it's not particularly easy but

also not very difficult.

I think this is the way how we demonstrate the use of the robot to do the operation because

nothing is clearly identified, if not because of the robot you might have a bit of concern

and how to dissect

and also

with a bit of difficulty when you try to

close the chiropractic.

Don't do that.

Don't do that.

I would never drink.

Oh, finally I hear

a voice.

Finally I hear a voice.

What happened? Finally I hear

something from Italy.

It's broken.

Is it out?

OK, I think that's it.

That's it.

OK.

捉咗條 string先啦。

捉咗條 string先。

捉咗條 string先。

OK.

走埋去,走曬去。

一,二,走曬。

好,走曬。

I know you can't...

I can't hear anything from you,

but this is how we perform the

the robot assist the prosopic cholecystectomies also exposed shouldn't have come about it.

I think the tricks of the whole surgery, you need a very careful PRP depending, you know

what pathology you are dealing with, even though in the presence of multiple abdominal

surgery and you evaluate what would be difficulty you can encounter when you are doing the operation

and insert the first choker safely with the use of optical choker.

Second, would be a team approach.

The console surgeon has to work with the backside surgeon

and do surgery together.

Third, I think the enhanced visualization

in terms of use of ICG, 3D vision,

and also the intra-frontal vision sound

do help me a lot to define clearly the anatomy.

Last but not least would be the dexterity confirmed by the robotic arm.

And in fact, I enable you to do the posture of the cystic ducts thumb,

as well as they call it, quite well.

And I think that's the end of the live demo.

I'm so sorry I can't hear anything from you.

I hope you are fine with the surgery.

I didn't use up the whole two hours.

I just finished the surgery in one hour. I hope you don't mind with it. Hope I can have chance to

Involve in any one of your workshop in the future and thank you

Thank you once again and all the best from Hong Kong and this is the end. Okay, I think that's the end of the live transmission

Bye bye