SEON HAHN KIM da Vinci (Si &Xi) Low anterior resection

Hello. Hello. Hello, Professor Kim. Yes. Hi. This is Kim. This is Marco Vitellaro from Milano. Also, Guglielmo is here with me. Hello, Gugli. I can see you behind. It's a pleasure to meet you. I cannot hear you very well.

Professor Kim, it's a pleasure to meet you

maybe now you can hear me better

yes, yes

very glad to see you

I'm happy to see you too

how are you?

I'm very fine, thank you very much

again, congratulations on your

finishing all the

process

thank you very much professor

for becoming

a real surgeon

alright, good

We are preparing ourselves for the demonstration that will be in less than one minute.

Do you have any information?

Basically, totally robotic, single docking, meaning robot cart does not move,

and double targeting with arm repositioning, meaning I have two different phase of procedures.

procedures. Firstly colonic face, secondly pelvic face. And I'm using two left hand technique.

What is two left hand technique? The scope is here and you can see two robotic working

arms on my, on the left side. That is two left hand technique. This is my SI port layout

out here scope and right low quadrant 12 millimeter for stapler and later stoma

and I mostly extend the wound for specimen extraction on left low

quadrant here and I have one five millimeter port for my bedside assistant

what that means here who the robotic arm move here and I'm three robotic arm over

here so I'm using these three for the pelvis for that my assistant can use

both hands using these two ports this is how it looks like from the outside and

this is a view from the patient head this is leg and side ducking here scope is here two left hands

one right hand my assistant using two hands mainly right hand for suction left hand for traction on

the rectum this is a case of low rectal cancer after long course chemo radiotherapy eight weeks

after the completion of radiation here very much responded

my right hand is arm 1

monopolar scissors

my main left hand is arm 3

here is bipolar

very len

once lifting up the

transverse colon

here

We can get into the lesser set.

You can see the space into the lesser set.

I am V-highlighted here, pancreas.

I know not many surgeons

use this technique

but this

IMV ligation

then very early

entering into the lesser sex

in order to dissect

both the pancreas

is very good technique

for sprain flexor mobilization

medial to lateral

or inferior

Professor Kim, this is a very interesting technique from bottom to up.

I know.

Okay, give us some tricks.

Trick is exactly the same as what you see in this video.

So after ligating the IMV, then lifting up the transverse colonic mesentery, then cut the peritoneum, then you can get in.

And later on, in my very short video with XI, you can see it again.

sacral pulmonary, then going backwards to the IMA area to preserve the nerves here.

Some nerve fibers going into the mesentery.

I can cut it, but the nerves going here toward the hypogastric nerve, I have to preserve.

So you can see the nerves here, the right side, left side.

again my right hand instrument is monopolar scissors the power is about 25 my left hand

is Maryland which is bipolar this is already dissected of the IMV here my assistant is

lifting up here you can see the zero touch fascia overlying the kidney so arm two which

is cardio for safety lifting up the mesentery after completion of the medial dissection then

i go laterally my assistant is using this five millimeter port on the right flank i'm dissecting

Just monopolar and bipolar is enough, mostly.

Turning around, momentum, assistant, giving me a traction on the colon.

Traction, counter-traction.

This is geratous fascia, kidney.

So even through the transverse colon, I'm just keeping the line close to the colon,

which is mostly a vascular plane.

because already the pancreas was dissected off earlier everything is free

from the splenic flexor it's a very floppy IMA and for the for the very low

ultra low type of resection it is better to divide the left collic artery from

from the inside and the upper part of the rectum is is mobilized using the

same position same troca so for high entry section this colonic phase of troca layout is

working now i'm using this second part of the troca layout is pelvic phase

here this arm tool here is mainly counter traction anteriorly or laterally

and my main left hand is arm three here and my assistant left hand is giving me

attraction on the colon and rectum and my bedside assistant right hand is

for the suction here this is assistant right hand as you see my main left hand

long course chemo radiation the tissue is slightly edematous but it's okay because my assistant

vesicle here. This is just normal speed. And this is one of my technical tips.

Both in male and female, I'm using this traction suture. Of course in female to the uterus,

but even in male just on the peritoneum below the bladder is very useful. And also this

nylon tape around the rectum at the level of sacral promontory is very good for traction on

the rectum by my assistant. Assistant left hand is holding that tape and traction. This is rectum.

you can see the levator ni muscle here seminal vesicle the right side of the

levator ni turning around anteriorly here going toward the left side here

ligament so I'm trying to dissect the ovs anococcygeal ligament you can see

later more clearly. Here, left seminal vesicle. My left hand is bipolar. You can see the left

side of the levator ani. This is left posterior side. I'm trying to get into the intersphincteric

space posteriorly. Here, you can see very clearly the anococcygeal ligament. Anococcygeal

ligament is smooth smooth fiber connecting the posterior side of the

lower rectum and actually upper anal canal to the coccyx. Once I divide it

that is inter-sphincteric space. This is the levator ani rectum so I'm trying to get

into the inter-sphincteric space here right side counter traction is good

technique when i'm using the robot anterior part is most challenging part you can see the longitudinal

muscle of the rectum this is below the almost below the prostate you can see that recto

urethralis muscle here if i go here is urethra if i go here is rectum so this is the most challenging

This is actually almost the external sphincter.

This is the levator, puborectalis.

I would like to thank Dr. Piochi, Gulli, for editing this video.

Thank you very much.

You're welcome.

So checking the tumor location by finger.

So after applying stapler somewhere here, that was two fires mostly and green cartilage.

This is the final view of the pelvis.

So my own definition of Da Vinci SI, XI surgery is surgeon-controlled multi-arm operation.

And the key aspect of multi-arm operation is how to optimize the use of multiple arms

in order to maximize the success of a high-standard operation in minimal difficulties.

Today, you saw just an example in this presentation.

As you may realize, every each step is very much standardized,

and Xi is nothing different from Si except troca layout.

Again, this is Si troca layout, but Xi is slightly different.

I'm using this technique.

Scope is here, meaning I'm using two left hand technique.

Specimen extraction, stoma same here.

This is after putting the robotic trochus here.

For colonic phase, I'm using these four.

After target anatomy toward the middle of the descending colon here.

Camera here, two left hands.

this is how it looks like

camera to left hand

12mm on right low quadrant

yes

you can see it again

I am V first technique

here I am V

this is not very long video

this is short video

so this is transverse colon

ok now the tricks

yeah this is the trick

after lifting up

the transverse

colonic mesentery

here

Here, you can see groove here, transverse colon, mesentery, and pancreas.

So, about one centimeter above that groove, a flexion, cut the peritoneum here.

Yes, now I get into the lesser set.

Very simple.

Of course, if the patient is obese fat, it takes a little more time,

but the concept is exactly the same here lifting up yes so this is pancreas so sometimes there is

a small vessels or adhesions you can cut it now here this is pancreas just going through the

pancreas tail so this is this is stomach you can see the stomach and after that this is different

patient I sometimes I start I am I am a ligation first as conventional usual way

but anyway either way is okay but I would say almost nine eighty ninety

percent of my case I thought I am V first technique so same so I'm using

this trochlea so for after medial lateral then lateral attachment

definitely compared to SI this spleen fracture take down around you can see

the spleen is if I'm using the

XI which is slightly easier

than SI no doubt because

the second left hand is more flexible to use

if I'm using XI compared to SI

so after colonic phase of dissection pelvic phase

I'm using these four and the target

anatomy is mid-pelvis. Assistant has both hands working freely, exactly same as SI.

Here, assistant uses two hands, same as SI. Perhaps this is the last video, short

video. So arm one here is my second left hand. It is mostly using traction,

counter traction as you see my main left hand Maryland is like my finger finger

retractor this is left posterior lateral same traction suture this is left

like to thank Dr. Piocchi for editing the SI ultra low entry section video, which I showed today.

Thank you very much, Professor Kim. Angelus, I want to come to see you in Seoul.

Please, please. Thank you very much. It was a great lecture and obviously with great images

and we have a clear technique where it's possible to learn.

So, really, thank you very much.

We really appreciate your presentation.

Thank you very much.

So, I have to say goodbye.

Yes, we'd like to see you if it's possible.

Now we see the PowerPoint presentation.

Oh, okay.

Okay, here we are.

So, did you enjoy?

Yes, yes.

Thank you very much

and hope to see you next year, okay?

All right, okay.

On behalf of Professor Palazzini, really,

thanks a lot for being part of the conference in Rome, okay?

Yeah, this is my great honor.

Thank you.

Okay, ciao.

Bye-bye.

Bye-bye, ciao.