Prof. LIU LIANXIN TEAM Prof. WANG JIZHOU Laparoscopic Hepatectomy

I need feedback. It's time to introduce this case, the first case.

Okay, you can introduce the case background.

Oh, yeah, yeah. Okay, okay, okay.

Hello, everyone. I'm Ji Zhou Wang. I'm one of the colleagues of Professor Liu Lianxin.

Well, it's my honor to join this great meeting, and I will introduce our case.

Well, next.

Next, the patient is a male, seven years old, so the height is 166 and the weight is 80

kilograms.

So we can see the BMI is high.

The genetic complaint is a liver tumor was found three days ago when the patient was

admitted.

So there is no special history of other disease in the past medical history.

the physical examination is normal.

So let's see the laboratory examination.

So the blood test is normal.

The function is normal.

So the coagulation function is normal.

We also test the tumor macrum.

The FP is normal.

The CA 99 is normal,

but the PV car is a little high.

So we also do the virus test, for example, hepatitis B, hepatitis C, it's normal, it's normal.

So let's see the enhanced CT scan of the patient.

We can see a tumor mainly located in the segment 6.

So let's see the diagnosis.

So let's see the portal vein.

So we can see the red posterior portal vein mainly supplying the tumor.

Yeah, this is a hepatic vein.

So that's interesting.

So we can see the tumor is mainly located in segment 6,

but we can see the blood supply of segment 7.

Yeah, we can see some branches from segment 8.

supplying the segment 7

so when I block

the right posterior branch

the pedicle of

the liver

so we can see some demarcation

area

so my plan is

I will do a portal wing

territory based

anatomy

first I will mobilize

the liver then I will

find the right posterior

pedicle of the

glycine, I will find the demarcation line

may be the main part

of segment 6 and some part of

segment 7 will show the demarcation. But

I guess some of the upper part of segment 7

is normal because there are two branches of the blood vessels

from segment 8. So, of

Of course, during the operation and all the brachymal dissection,

I will use laparoscopic ultrasound to monitor the resection margin.

So, that's my plan.

Is that alright?

Any questions?

Hello?

Can you hear me?

Yeah, yeah.

Good.

The line is good.

This is Dr. Grazi from Rome.

I work in Florence.

and I wonder if you perform an MRI in this patient or just the CT scan?

No, no, no. Of course, we do the MRI, the enhanced MRI.

So the diagnosis of the MRI is, they suspect the tumor is central adenocarcinoma, yeah.

And this tumor has been found just three days ago?

Not three days ago, three days before the patient was admitted, yeah.

Okay.

Yeah. Is that right? So if there is no question, I will watch. Okay?

Okay, go ahead.

Yeah, thank you.

Can you show us where you are going to place your trucker for the operation?

Oh, of course. I will show the arrangement of the trucker. Right. Okay.

Okay, that's one minute.

Teacher, could you man the show the tracker and why the position you placed?

Oh, yeah, yeah, yeah.

We use the 5-4 to do this procedure.

Yeah, yeah, yeah, of course.

And for your position and so on.

Oh, yeah, okay, okay, okay, I will.

Okay, so today I will use Einstein region of the 3D microscopy.

you know, this is the latest region of the 3D microscopy.

Yeah, one thing I want to introduce,

yeah, this endoscopy is a little different

from different brands, from other brands.

So you can see there is a sheet.

We can use a sheet to cover the microscope, yeah.

So we don't have to do the sterilization

for the camera you know so we don't have to you know sometimes we have to wait a

long time after we finish one operation for the sterilization

otherwise if I have to buy two cameras for one machine I will pay

extra money for that.

So if you use

this sheet,

so it's very

I can save a lot of time.

So let's see the

abdomen of

the patient.

So maybe someone

is very interested in how

I place the trochlea.

So let's say it's a belly button.

So I think it depends

on the shape

of the abdominal cavity.

So if the ship is very small, the cavity is very small, I prefer to replace the first trucker under the belly button.

But if the cavity is very large, I prefer to place the first port on here.

If we do the lesion on the right posterior area of the liver, I prefer to place the trochlea

on the right of the bottom.

It depends on the shape and the lesion.

For this case, the BMF for the patient is high.

The body weight is 80 kilograms.

is yeah yeah yes yes okay first i will use the needle okay so the pressure of the i will set

the pressure is 14 please set set the pressure 14 yeah 14 right yeah 14 yeah oh yeah okay and the

The floor is faulty, yeah, right.

My first assistant will stand on the left side of the patients.

But as I know, some doctors or professors in China,

for example, Professor Liu,

they prefer to stand on the left side of the patients as an operator.

So what's the situation in Europe?

Well, it depends. It depends on the type of surgery we have to perform. It depends on the size of the patient. It depends on what kind of operation we have to do. So I do agree there is no standard position, but the position that is more comfortable for surgeons.

Yeah. Yeah. Yeah. Yeah. Yeah. I use a head up a height. Yeah. The height is very high. So I can, um, make the bow. We'll go down. I have enough, uh, cavity for the operation. Right.

Yeah. First I will do the explosion of the, uh, the whole cavity. No, uh, uh, the mortality. Okay.

Okay.

Okay.

So now I will set the two trucker for me,

the main one and the assist one.

Okay.

Just to show, show it, okay.

So we can see, yeah.

So this is a cavity, the area of the abdomen.

So this belly button.

So the region is here.

So I will place my main trochanter at this area, just around the middle clerical line here, and the assist trochanter here.

So the lesion is here. And my assistant will set his main trochanter here, and the assist trochanter here.

That's the curve. That's the curve to the legion. And the distance for every trocha is one feet, just 10 centimeters apart. All right?

Do you have any experience in placing trocha between the ribs, intercostal trocha?

I prefer to use the harmonic scapula.

And sometimes I use the orthosonic dissector.

First, I will cut the round ligament to mobilize the liver.

And then the phosphor ligament.

Do you take down the ligament also in a cirrhotic patient?

Sorry, the ligament what?

Cirrhotic patient with mild portal hypertension.

Did you take the ligament down or you leave the ligament to prevent further portal hypertension?

Yeah.

So, yeah, my sister will place the trucker for him.

Yeah, okay.

Will you use the Pringle maneuver during the resection?

Yeah, yeah, great, great.

We can see the lesion, right?

Some lesion with the omentum?

Yeah, yeah, yeah, here.

So, pre-diagnosis is a cyst, I don't know, carcinoma, yeah.

Yeah, so, okay.

Okay, I'll put this down.

Hurry up.

so I have to dissect it to show the lesion, right?

I see that the lights in your operating room are all open.

Oh, yeah, you prefer to switch off the light?

Yeah.

是这样,这个,他们想把这个手术室的灯关掉,是我们这个手术灯是开吗?

So you prefer to switch off the light in the operation room?

对,稳一点,OK,你从你那边,你从你那边,好好,OK,好,去吧。

Which kind of screen are you using? 4K or what is the type of screen where you are watching the operation?

Oh, 4K. Okay, it's very good. Yeah, I love it.

I love you too.

Good. So, I'm not quite sure about the long quality. So, what about the quality of the vision in your screen?

legion. So I use the ultrasound to localize the legion and some of the landmarks in the liver.

It's very, very useful. So you need to free the liver also for performing the

interpretative echography? Yeah, yeah. First I will do some mobilization of the liver,

because I can't place the detector in some area

before I do the mobilization, right?

It seems that there is an adhesion

but not a tumoural infiltration.

Oh, yeah, yeah.

This way, this way.

Take it up.

This mirror seems to be dirty again.

The mirror is dirty again.

Let's check it again.

The person is fatter.

Let's turn the mirror over.

Turn the mirror over.

So, according to the appearance of the tumor, I think it's malignant, right?

Let's see, maybe.

I hope it's benign.

but unfortunately according to the

experience in my opinion

I think it's malignant

I think so

poor guy

is it common in China

not very common

we do have a larger number

of CC in China

but such kind of patients

usually have diabetes B, diabetes C

there are some

cirrhosis

liver background

liver fibrosis

But this patient, I think the cause may be the, oh yeah, for this patient, the hepatitis B and the hepatitis C is negative.

This adenocarcinoma, I don't think has any risk factor known.

Yeah, yeah, yeah, yeah, yeah.

Yeah, I agree with you.

It's an interesting case, I think, yeah.

Yes, I feel the same.

It's a very interesting case.

Yeah, yeah, yeah.

after the pathological report

I got

I will send to you

after the operation

we got the pathological

pathological report

I will send to you

yes

this is Hongguang

speaking

Oh, hi, Professor Wang. Hi. Okay, I have a question for you. Yeah, yeah, yeah. The diagnosis of this patient, maybe the ICC. So did you... I'm not quite sure about that. Yeah. Did you have a pre-operative PET-CT scan to get the lymph node metastasis?

the lymph node is negative, but I'm not quite sure whether I will do the lymph node

dissection or not. I think it depends. I'm not quite sure. Maybe I will do the lymph

node dissection. It depends on the time. Maybe if there is a time limitation, I will not

not broadcast the procedure of the lymph node dissection.

If the time is permitted, I will show it.

Okay?

So how about in Italy, Professor Susskind,

for the ICC, intrahepatic cholinergic carcinoma,

Did you have the optive PET-CT scan to obtain the lymph node metastasis?

I'm Professor Grazi. Professor Cescon is not yet available for this connection.

He will be online in a few minutes.

Oh, yeah. I'm sorry.

No, that's okay.

Actually, we don't do the intraoperative

PET-CT. So you're doing intraoperative

PET-CT for phase one.

You do the

intraoperative PET-CT

before the operation

you prefer the PET-CT, right?

Yeah.

I know the data of

Gao Qiang.

So, you know,

if the patient is

is IDC.

Yeah, yeah, yeah.

Where you perform the lymph node,

lymph-

PET-CT before operation, right?

Yes.

Oh, that's a good question.

Actually, yeah, if we redo the PET-CT before operation,

sometimes we can find the distal lymph node metastasis.

For example, yeah, the lymph nodes in the thoracic cavity

CT or number 16 around the aorta, but we don't do it routinely because the patient has to

pay extra money for it, it's very expensive.

But if the CT scan or MRI before operation, we suspect there is maybe metastasis, we will

suggest the patient to do a PET-CT. For these patients, it's not an ICC. According to the

report of the MRI, it may be cyst adenocarcinoma. I'm not quite sure.

But cyst adenoma, maybe it's a kind of adenoma. Yeah, adenocarcinoma. Yeah, I agree.

Okay, I put the band for the Pringle, okay, okay, I leave it here, okay, please give me the auto sound, okay, okay, okay, okay, okay, okay, okay, okay, okay, okay, okay, okay, okay.

So the liver is not normal looking. So the shape changed. Yeah. Okay. We can see some shrinkage of the left lateral lobe and the change of the shape of the whole liver. Yeah. Let's see. Okay. Oh, unfortunately, you can't see the screen of the ultrasound, right?

We are not watching the ultrasound.

We cannot see the ultrasound.

Oh, I hope you can see.

So would you please...

Yeah, would you please...

你可以把这个对准,这个 ultrasound呢?

Yeah.

或者把这个放在这个位置。

不行,不行,你放在那个位置,他们也看不见。

Okay, okay, okay.

我在你那边,我在你那边。

Oh, you can see that?

Oh, great, great, great.

You know, Professor Wang, in Suzhou, he is a very, very famous surgeon in China who performing

the laparoscopic ultrasound for the liver hepatectomy, for the laparoscopic hepatectomy.

Okay.

So I prefer to use in the middle part to place the detector of the ultrasound.

So let's see.

first i will find the thank you to joe uh i can say uh you are using the no blast is that oh yeah

yeah yeah of course uh can you set the depth of the ultrasound

no no no okay okay so do you do stand at the

the left side of the patient.

Oh yeah.

I stand on the left side of the patients.

So it's a left lateral top.

Yeah. So this is...

So pay attention to the simple.

Okay. Okay.

Maybe that the image is worse.

Oh yeah. Yeah.

I know that.

Thank you, thank you, can you set the direction of the detector, yes, yes, yeah, yeah, okay, great, great, thank you, oh yeah, yeah, so this is anterior, right anterior pedicle,

Yeah, I'm not sure, can you see it?

Yes, we can see it.

Oh yeah, the right anterior pedicle, right?

So it goes up, up, and this is the dorsal branch of the segment 8.

No, no, okay, let's show you.

No, yeah, here, the right anterior pedicle, right?

What I found is the right posterior pedicle, right?

Yeah, the red posterior pedicle, right?

Let's continue. We will find the lesion.

Here is the lesion, right?

Okay, so my plan is to block the red posterior pedicle.

I will see the demarcation line.

But according to the preoperative 3D reconstruction of the liver,

However, there are some small branches from the 8th pedicle to supplying the segment 7th.

So I'm not quite sure, after I block the posterior pedicle, is it enough to get a safe resection

margin?

So during the resection, I will use ultrasound to monitor, right?

Okay.

Yeah.

Let's see.

So are you planning to perform the anatomical resection of Segment 6?

Not Segment 6, maybe including some part of Segment 7. We call it portal wing territory-based anatomy liver resection.

Portal wing, depends on the demarcation line, right?

Yes.

Okay, good.

Good. So you mean some part of right anterior ventral sectionectomy will be performed, yes?

Sorry, I mean some pedicle in the dorsal segment 8 supplying the segment 7, yeah? Are we clear?

Yes.

oh yeah yeah yeah so after i blocked the right posterior pedicle yeah the the demarcation area

maybe can't cover all the segment seven right uh so right posterior second neck to me uh

common with the right anterior dorsal segmentectomy yes yeah

Yeah. So after I block the posterior, right posterior pedicle, I will see the demarcation line can cover all the region.

Yeah, it depends. I'm not quite sure.

But I guess, you see, the right posterior pedicle, usually there are two branches at the beginning of the right posterior pedicle.

如果缺血的区域能够覆盖肿瘤,我就不去,我就不做一个完全的右后页切除了,就是按你们卖流域了,因为有部分七段隔顶部的这个分支呢,是来自于八段的被测值,对,所以说来,来自于八段被测值,我去找他就要比较困难,对,我必须把肝劈开才能找到他,对。

So, Professor Grady, in Suzhou, there are some Chinese students.

So, sometimes we have to do some Mandarin.

So, I hope you do man.

How will you approach the pedicles?

From here, will you perform extra-Gilsonian approach to segment 6?

Okay, so we can see the perforation of the right anterior and the right posterior, right?

Yes, right.

Yes, this is an extra-glissonian approach.

Oh, you like it?

I like it very much.

Yeah, yeah, I prefer to use this one.

This way, okay.

I think it's very useful.

Yeah.

In this case, the pedicle is clearly visible, so...

Oh, yeah, I'm a lucky guy.

You're a lucky guy.

Yeah, okay.

Call that brand?

Oh, maybe the brand should cover it.

Yeah, yeah, yeah, yeah, yeah. The small branch to the caudal lobe, right?

Right.

So there are some small branches we have to cut to mobilize the pedicle, right?

A little deeper, okay.

Sometimes here you can find some small hepatic veins.

the problem is that they bleed

and the operating field

became

dusky

actually

I don't do the ligation

because the ligation sometimes is not tight enough

I probably use

a clamp

alright

open

just another question for you

Sometimes the demarcation with the endogenous green is more clear than the ischemic demarcation.

Yeah, yeah, totally agree. Sometimes we can see the demarcation line only on the surface of the liver.

Yeah, in the perectum we can't see the demarcation line, right?

Correct.

Right, okay, so we can see the demarcation line. Is it clear? See?

Yes, we can see it.

Yeah, good, good, good.

Okay, clean the camera.

记住,高布莱德玩得很快。

Thank you, thank you.

I'm one of your students.

I'm a good student.

No, no, no.

Yeah, okay.

The teacher.

I learned this part from you.

Okay

So we can't see the democracy around this area

I'm not quite sure

Yeah, of course

The location

So I have to continue to mobilize the labor

To see the democracy in this area, okay

I think the labor needs to further mobilize

You see

I'm not quite sure, okay

Okay, let's have more flexibility, okay?

Okay, give me a gauze.

Okay, okay.

I think the lever needs further mobilization.

Okay.

Okay, I'll adjust it, you can turn it.

Have you seen the inferior vena cava yet?

No, so that's why I need to do a further mobilization.

Okay.

Are you performing a kind of hangar maneuver?

No, no.

For the open way, I will use it.

But for the laparoscopic way, we don't have...

We have different regions, so we don't need...

Sometimes, mostly, we don't need the liver maneuver.

Wait a minute.

Don't worry.

Okay.

I prefer this way.

I will place the camera in my...

You will change the trocker.

Yeah. Yeah. Yeah. Great. Okay. Okay. Okay. Go. So the camera now is more on the right side of the patient. Right. Great. You can see you can see more clearly now the ligament. Yes. Yes.

So, when you press the pressure on the IVC, how about your blood pressure?

Oh, yeah, yeah, you know, the low CVP, the blood pressure.

What's the blood pressure?

Is there a low blood pressure?

Yeah, let me have a look.

Okay, so 血压是多少现在?

73 多少?

Oh, the blood pressure is 70 to 40.

A little low, but it's okay.

We monitor the volume of urine

to make sure the blood supply of the mental organ is okay.

Okay, 再回来。

就是想在这个游离的过程当中

血压一般都会下降的。

这时候让医生来沟通。

Yeah, yeah, yeah, yeah.

是的。

The liver honing can cause a twist of the cover,

the venous cover,

so the blood pressure will get down.

So we have to communicate with the anesthetist

to tell them that's why the blood pressure dropped.

The pressure dropped because we moved the liver.

Yeah, cause a twist of the venous cover.

Okay.

Yeah, yeah, yeah, yeah.

You should take the goldbladder out.

Yeah, good suggestion.

Now you're approaching the interior of the cave from this side.

Yeah, yeah, yeah, yeah.

Okay, this way.

So we can see the demarcation line here.

So there is a main branch for the cauldron lobe here.

Okay, okay, fine, fine, I will cut it off.

Because actually I'm a little nervous to do the operation before Professor Wang.

You know, as I said, I'm one of the students of Professor Wang.

I'm a student of the Escalab School, College, to do the laparoscopic hepatectomy.

Yeah.

I know you are the leader.

Yeah, there are also some students in Suzhou here.

It's a good opportunity to learn laparoscopic hepatectomy.

You know, in Suzhou, there are some good devices, the best laparoscopic in Suzhou, and we can

do some animal operation, yeah, it's very good for us to practice, yeah, the laparoscopic

I agree.

Is the tumor very hard, or is it soft?

Now you can...

A little hard.

It's some kind of adenocarcinoma, so it's hard.

It's not typically ACC, the feeling.

So we can see the dorsal part of the segment 7.

There is no blood supply, right?

Yes.

Okay. Let's continue. Continue. Come on.

Yeah. Okay.

So the tumor size is a little large, near 9 to 10 centimeters.

And this patient did not complain of any symptoms because of the tumor?

Yeah. No abdominal pain.

Yeah. Just some discomfort.

comfortable yeah he found the liver uh legion just in the routine physician physician physical

examination okay let's continue okay come on no no no no no no the patient from your

from your town or is he coming from outside your town yeah yeah just yeah i will promise

Anhui province, one of the province in China, in the east of China, come on, see, go, go, go, go, go.

This is the upper part of the liver.

Yes, yes, the segment 7, yeah, I can see, we can see some bleeding from the gland.

The diaphragm.

Yeah, yeah, yeah, okay, okay. Yeah, I prefer the bigger clamp to do the coagulation.

这边还是要往回来一点,往回来一点,好,好,ok,no,no,下面的用点力,床又高一点,so it's a window cover, the bumping, the bumping of the window cover, ok,ok,ok,so we can see the demarcation line, no, no, no, no, hold, hold, please, hold, please, we can see the demarcation line, right, ok, let's see the demarcation line, ok.

Okay.

So we can see it.

Yeah, yeah.

No, no, this is the demarcation line, right?

If we use the fluorescence, the sense is very good.

Yes, I do agree.

Yeah, but today we show the 3D.

The main help of ICG is that you can clearly see

the demarcation line inside the liver oh yeah yeah yeah i totally agree

here right yes we can see clearly the demarcation line behind the liver yeah yeah

This is coded lobe. This is the border between the right coded lobe and segment 7.

Let's see the segment 7.

And the coded lobe on the other side of the material.

Okay, okay. No, no, no, no, no, no. Show me the right, okay.

翻起来,慢慢来,你翻的不对。

Okay, there is a small vein here.

Okay, give me the beaker.

Are these bipolar forceps?

Kind of bipolar.

We call it beaker, beaker clamp.

Okay.

Herb.

Okay.

功率是多少?

These bleeding are very annoying.

Yeah, yeah, yeah, I agree, I agree.

那个电钉,那个电钩,那什么,那个电磷棒。

This bleeding make a waste of time.

Yeah, yeah, great.

Oh, my God.

好,你倒一下,你倒一下,把肝彻底立起来,老宋,你把肝彻底立起来,对。

It happens to everybody of us.

老宋,请给我冲洗一下,谢谢。

Will you put some coagulant on that?

No, no, I will use this one.

对,对。

I think it's one of the hepatic wing.

Yes.

More hepatic wing.

Yeah.

Good.

You got it.

Yeah, yeah, yeah.

谢谢,把水洗走。

Okay, okay, good.

我看不见,这是视像线。

Do you need to cut the dorsal attachment of the inferior vena cava, the makoushi ligament, or not?

I'm not quite sure. It depends, I think.

Because I will do the liver resection along the marcation line.

Sometimes I have to cut off the caudal loop.

Sorry, I need another clamp.

Yeah, yeah, yeah.

Because I preserve the blood supply of the caudal lobe, right?

Yeah, so maybe in this case, I do not have to cut off the Makuchi ligament.

But this is okay.

Okay.

This is blood supply of the adrenal gland, right?

Adrenal gland.

Right, adrenal gland.

Yeah, right, adrenal gland.

Right, right, right, right, right.

Okay.

Oh, finally. Good, good. So, we can see the demarcation line. Come on, come on. Yeah.

Because I preserved the branch of the coated lobe, so there is no demarcation, so I will cut along this line, right?

Is that okay?

The coated lobe is safe.

Yeah, yeah. Okay. So, we can see the coated lobe was enlarged, I think.

It's not a normal caudal lobe, it's a large.

I saw your 3D reconstruction of the veins of the liver.

With the 3D reconstruction, did you perform also the segmentectomy of the liver?

Could you see how big the caudal lobe was?

Oh, the volume, yeah.

Of course, we do have the data of the resumé volume of the liver.

Of course, it is enough, so I do not pay much attention to it. Sorry.

Okay, I understand.

Oh, yeah.

There's some bleeding from the adrenal gland?

Yeah, yeah, yeah, yeah. I'll control it. Good. Under control. Okay. Come on.

Okay, let's continue. Yeah, we will do the paracumar resection, okay? Shall we?

So, how about the blood pressure now?

Yeah, the blood pressure. Oh, okay. How about triadrotol?

Oh, the pressure increased to 90, right?

Is that okay?

Okay.

Okay.

What will you use for a parenchymal dissection?

The CUSA?

Oh, sometimes I use CUSA,

but it's time-consuming.

No, most of the time I use the ultrasonic harmonic.

Okay, let's see whether the demarcation line

can cover the lesion.

Oh, it's a little dangerous, yeah.

So we cannot see the ultrasound image.

Yeah, I think it's a little dangerous.

Oh, maybe I will cut the lever here along this line.

It's a little dangerous, yeah.

So the plan is to remove Segment 6 and a portion of Segment 7?

Oh yeah, yeah, yeah. See?

Why not to remove the entire Segment 6 and Segment 7?

Oh, you mean the entire Segment 7?

I will cut off the dorsal part of Segment 7, but the ventral part...

Okay, let's see the ventral part.

So ventral part, as I said, sometimes some branch

from segment eight supplying the ventral part

of the segment seven.

So according to the demarcation line,

no, I'm just finding maybe it's not large enough.

Okay, I will use another port to see.

Are you moving the ultrasound probe?

Yeah, yeah, I don't think it's safe, it's safe enough. Okay, I will move, maybe I will plant the resection line here.

This is enough. Okay?

On the left part of segment 5?

Yeah, maybe I have to cut off some part of the segment 5. Yeah? Is that clear?

I will try. Thank you.

I will try.

这好难啊。

对,这个人他这个杆扭得很厉害,变形。

好吧,我把这个杆劈开,我试着去找一下。

I will try to find branch to segment the dorsal part of segment 5.

王立军,王立军。

实际上前列这个平面是固定的,

大家做多了就会发现,

这个就是就像我们的左右半杆之间的

这个主门脉裂是一样的,这个前裂也是固定的。

进来,你看就碰到了这个微五。

王理进,不是不是不是,把课钱给我。

这个脚踏,脚踏我看不到,你给我递到我脚上。

Just a comment for you.

You don't like to perform the hemi-hepatic vascular occlusion.

just to closing the right branch of the portal vein and the right branch of the

artery in these cases sorry I'm not quite the line it's not good can you

hear me now the line is not a very good can you repeat your question yes I saw

your extra hepatic approach I'm wondering if you don't like the

the hemi-hepatic vascular occlusion, I mean just closing the right branch of the hepatic

artery and the right branch of the portal vein?

No, maybe not. My plan is to find the dorsal part of the segment VIII, cause as the demarcation

Professor Wang, I think this branch, the dorsal branch, maybe is that one I need to find.

Okay, this one, okay?

Oh, it's very deep.

Quite deep.

Yeah.

Come on.

The small branch is broken.

Yes.

This will make my oil pressure a little better.

Okay, come on.

Come in, come in, come in.

Open it.

I think it's almost there.

The pedicle is not clamped at this moment.

可能还要偏右一点,记住我觉得,偏右的分离,这个万一是一个包含了这个一部分辐测段的这个主干呢?

我先把它,我想选调一下,我想掏过去选调一下,但现在好像有点困难,对,我想选调一下,来,我再接着批,来。

这个角度可能是,刚好是它主干的背侧,如果你偏右一点,可能能把它直接掏出来。

Maybe there is a dorsal vessel. This is a main branch. This is ventral. This is maybe here is a dorsal.

Ventral, this is dorsal. Anyway, 过来分离前。

Will you close or will you clamp it?

Clamp. Clamp is safe. This is a dorsal one. Professor Wang, you are right.

过来分离前。我要给大家展示一下。

Okay, I see, this is the dorsal one.

Can you see it?

Yeah, you can see this one.

Yeah, I have to preserve this one.

Because that's why I can't go through that way.

I can go through this way, okay?

Climb.

Oh, we don't have another choice?

Now, let's see.

看这边,看这边。

瑞鹏把杆拽过来。

我要看一下这个杯层面。

这些怎么样。

他把杆拽过来。

展示给我。

你要干什么?

不是,我要看这边气血线究竟过没过来一点。

Yeah, yeah, let's see the demarcation line, right?

Gentlemen?

Yes, we can see it.

We can see it very well.

It's moved to the left, right?

Right.

I'm a lucky guy, right?

The margin is enough.

us. Thanks God. Will you check again with the ultrasound or not? I will check. Okay, okay. Okay, come on. Go, go, go, go. I just said some of the branch of segment 7 is from the right anterior branch. So see, I got it, right? Okay.

Okay, so the demarcation line moved to the left, so we can see, yeah, okay, great, the

The margin is perfect.

So when I place the detector here,

I can't see the tumor.

When I move to the right, oh, it comes, okay?

All right, so at this time it's enough.

So we resect the liver along this line, right?

Is that all right?

Okay, .

Okay.

先给我带好,你没有带好。

Okay, we block the liver again.

And see where is the bleeding.

打开,洗一下,带个香给我。

没事,没事,no, no, no.

This is the bleeding.

帮我调一下这个线。

Is the bleeding from the liver surface?

Maybe.

Also, it's much better now.

Maybe it's more artery?

I will find it.

来,洗一下,洗一下,把这血都洗走。

好好好,Let's see where is the bleeding, then have a look.

Come on, go, go, go, that's better now, right?

Okay, let's go.

Oh, let's clean, clean the camera.

啊,阻挡了。

谢谢。

Come on, 够个胃前,胃前够一个,够一个胃前。

在这儿吗?

看我的超声刀,好。

This is harmonic scalpel.

Yeah, yeah, yeah.

I like it.

What kind of device do you like?

I don't have a great preference. I use a harmonic scalpel, I use a Cusa.

You use Cusa? I like Cusa, but sometimes it's a little time-consuming, yeah?

It's definitely time-consuming, for sure.

Yeah, but the Cusa is safer, yeah? It's very safe when you mobilize the vessels.

Okay, Sasha.

With this instrument, you can also do some kind of crash clamping for dividing the pranks, but I think it's very useful.

关键老外,他还有一场呢,咱得快点。

他还有一场,我表演完他表演。

Sorry, the interpreter, you do not translate our conversation, okay?

It's okay.

Okay.

Anesthesia are happy of the pressure?

Sorry?

The anesthesia people, the anesthesia are happy with the pressure of the patient?

Hello, CWP.

我有点私心,我是为了方便,我把这个,这个,这个,这个,避掉。

You didn't place any clip or hemlock since, since now.

Yeah, yeah, cause we do the anatomical, haptectomy, there's no big branch, right?

It should be like this.

Yeah.

这叫钱。

Okay, okay, give me 100 yuan.

Actually, I have a puzzle.

I have to do the...

Please don't plug in the cable again.

Yeah, when we do the posterior,

red posterior resection,

it's very hard for us to decide the resection plan, right?

Yes.

What kind of landmark do you use, professor?

Well, we use mostly florescence.

Florescence for us is more...

Yeah, yeah.

Oh, thank you.

Okay.

Negative or positive staining, it depends on case by case,

but negative or positive staining.

Yeah, yeah.

It's very easy for us to control the plate, right?

This is the posterior plane of the resection.

Now you're reaching the hepatic veins.

Yeah, yeah.

But there's some...

Okay.

There's some change sometimes for the right hepatic vein.

If we are lucky, we can see it.

Okay.

往里进,往里进。

再来一个,再来一个。

剪刀,分离前给我。

我好像有一只在出去,我要看一下。

Is this a small bi-duck?

Yeah, yeah, yeah.

I mean, I plant a piece of small clamp.

Oh, I prefer to place a small clamp on it.

Are you still on the Pringle maneuver?

The pedicle is still clamped?

Yeah, okay, good.

Let's open.

I want to check the demarcation line between segment 7 and 8.

It's a hard job.

Go, let's finish.

Okay, thank you.

Please give me time.

Very nice, very few bleeding.

Oh, thank you.

But some bleeding from the hepatic vein.

Yeah.

Because this is the posterior section of the parenchymal division.

Yeah, yeah.

Okay.

给我一块小纱布。

给我一块小纱布。

I want to see the demarcation line.

I don't want to waste time here.

OK, 洗一下,洗一下,洗一下。

Good, good, good.

OK, 瑞鹏,来,我们看一下demarcation line。

OK, 再给他来一块纱布。

OK, the demarcation line is here.

OK, we can cut around this direction, right?

This direction, OK.

OK, 电钩给我,我再洗洗。

Can I take a short break?

Yes, you should.

Thank you. Just two minutes.

I have to sit.

You know, as an operator, I stand.

And my first assistant sits all the time.

He's very happy.

Okay, I need one minute break.

Do you have any problem with the pneumo-peritoneum?

Yeah, I plan to place a liver honing to make my assistant comfortable.

comfortable yeah so so she don't have he don't have to hold the lever all the time right

对,我试一下,我试一下看怎么样。

我觉得可能起不到这个作用。

太好的作用,试一下吧。

实际上我做右后驱的切除,我特别喜欢切,

因为有的时候右后驱切的过程中就切偏了,

就容易往右偏,所以我喜欢把它旋起来,

我看看怎么样,你说的可能很对,

它没有太大的用处,怎么样?

A little better.

Your assistant will be happy.

Yeah, my assistant is very happy.

He's sitting, yeah.

Don't have to do a lot of work, yeah.

Okay, well, I want to see the demarcation line.

Okay, see the demarcation line

and the red fragnick, red fragnick beam.

I use this landmark to control the direction, right?

Yes.

Okay, oh, I use, I will use this beam, right?

This beam, okay?

This is an anatomical landmark.

Yeah, yeah, yeah, yeah.

are you listening in this direction very very very common very easy are you happy right okay okay

okay block you clamp her back oh yeah yeah go left to go to that uh how time fly five minutes past

we have to work again

okay

oh yeah great oh okay okay

Okay.

Are you activating the harmonic every time or just crashing the parenchyma?

I prefer the combination.

Yeah.

Okay.

Professor, have you ever been to China before?

Excuse me, I didn't catch.

Can you repeat?

Oh, yeah, sorry.

Have you ever been to China before?

You are really very welcome.

I've been a couple of times.

Hepatotectomy in the laparoscopic way, you know, patients have to pay extra money if we use Robic.

The Medicare can't cover all the money.

Insurance, you mean, the Chinese insurance?

Yeah, yeah. What about the situation in Europe?

Thank you very much. As I said, because the economic region, yeah, maybe 10 or 20, yeah, per week. Okay, thank you, thank you, thank you, thank you.

Okay, this is the border between the countertop.

Yeah, yeah, yeah, yeah. Okay, please give me enough money. I'll take it away first, it's a bit uncomfortable.

Yeah, yeah, yeah, yeah. If we cut along the winner cover, things will get easy. But because of the demarcation line, I have to preserve some part of the cauldron loop. As I said, the cauldron loop is a little enlarged, I think. Yeah?

Maybe.

Okay.

Now the pedicle is ready to be cut.

Yeah, yeah, it's safer and stable, right?

This is a very nice view of the pedicle, very nice.

Yeah, thank you, Zhijun. So what kind of stapler do you prefer? The white one, or the dapps? What kind of hemlock?

What kind of stapler, or hemlock?

Yeah, yeah, stapler.

The gold or the vascular, it depends.

You know, it depends on the...

Maybe, I don't know if you have the same problem in China,

but it also depends on the hospital supply.

Yes, yes.

We have the same situation.

Because at the beginning of the year, we have everything.

At the end of the year, in November and December,

everything is done.

Oh, yeah, we have the same situation.

Yes. Okay. Come on. Go.

Okay. Clear? Are you happy?

Okay. Very nice.

Okay.

Are you placing the stapler or the assistant is placing the stapler?

Who has control of the stapler? You?

Yeah, yeah. I. Yeah. It's good. Very good, right?

Very good.

The only problem is the hepatic vein that you will encounter in the posterior part of the resection.

Yes, yes, yes.

Okay.

Yeah, yeah, yeah.

There are very, very nice instruments from different industries, but this is very useful.

Yes, yes.

We were just talking about veins.

Yeah, okay.

Hamlet, hamlet.

The new type of hamlet can cut maybe 5 milligram vessels.

Yeah.

But, of course, I will not do that.

小心这个肝又静脉了。

对,对,差不多要到了。

有可能会要到了。

不管,我先批一批吧。

Okay, let's clean.

there is more and more oncological issues.

Yeah, yeah, yeah, yeah.

So I use the phrenic wing, subphrenic wing,

that direction, yeah.

镇头跟上,镇头跟上,努力地推。

Okay, 好好擦一下。

圆镜,圆镜,我看一下圆镜。

好, okay, time's up.

Let's have a short break.

Okay.

给我纱布。

You are performing an anatomical resection.

Will you drain the patient at the end of the operation?

Of course, I will.

Yeah.

Maybe I will keep the drainage tube for two or three days.

We will repeat CT scan.

If there is no fluid, I will remove the drainage tube.

You know, I know the fast-track surgery, the enhanced recovery surgery,

But sometimes there are some small bleeding, bowel leak can cause infection or cause problems.

So I tried. Actually, I tried before, but I changed my mind at last.

Telling the truth, in this kind of operation, when the resection is anatomical,

there are no major pedicle that have been, sorry, that have been cut.

I do not train this patient, and probably in this case,

I will not put a train for this case.

Yeah, let's see.

So let's say it's a posterior, right, posterior pedicle, right?

Right. So this is the dorsal part of the right posterior area, right?

Dorsal part. Dorsal part of the anterior pedicle, right?

This one and this one. Okay.

Okay. So we call it portal vein territorial-based anatomical hepatectomy, right?

Yes.

Okay, and talk about what we will do next, okay.

Professor Wang, okay.

Good, good.

Yeah, yeah, Professor Wang, are you here with us?

Yeah, I'm here.

Oh, yeah, yeah, yeah.

Any suggestion, any help?

You can tell some story.

Yeah.

There are a lot of people at the Suzhou conference.

Everyone is watching you.

Oh, I'm so nervous.

They are all my juniors, right?

Yeah, this way the liver is very thin.

Because I preserve the G1C, so I have to preserve this part of the liver.

Yes, correct.

Yeah.

Yeah.

Professor Grassi, can you hear me?

Yeah, we are the organizer right here in China.

May I ask, for the second operation, is the surgeon ready?

Italian surgeon, you mean?

The second surgeon, Professor Phyllis Gilliant.

Is he ready? The operation room is ready or not?

Because we haven't received any signal here in China.

I will check. I will check because I'm not connected with him.

So I have to check.

Okay, thank you.

They are asking if the other surgeon is ready.

I think it's too close to the right.

I think we should cut the lower meridians again.

Right, Mr. Song?

Because I don't understand.

记者主任,王教授出去离开了一下,他回来了,我告诉你。

好,好好,小心,小心,小心。

Is this the branch of the right hepatic vein?

Yeah, yeah, yeah, I mentioned, if we, I'm trying to find the vena cava, yeah, yeah, this is the vena cava, I will go along the vena cava, yeah, okay.

Okay.

Okay.

Can you talk after this?

Okay.

So this, he finishes this intervention?

Yes, I can.

Okay.

Because he's almost done.

Okay.

Okay, I'm here.

Up, up.

Up.

We cut too close to the right, do you understand?

So I try to go to the left.

We'll talk in English the same.

Wait a minute, down there.

But you said, we'll stop in six minutes,

because here, if not, we'll have hemorrhoids.

This is the vein.

Don't keep it.

Cut it off.

There is no bleeding from this vein, so the...

Yeah, yeah, yeah.

I prefer to cut the vein at the root of the vein, yeah?

So, we need some patience just to mobilize it.

Yeah, we can see the CP is quite good, yeah?

Oh, wonderful, wonderful, fine.

But will you leave this vein in the remnant liver?

No, no, no, no, no.

I will cut.

That's why I want to keep it. I just need him, need the wing to direct my, to help me to go to the second heli, to direct me.

Don't you think that the Engi maneuver will help you in performing the remaining part

of the resection?

Yes, I think so.

Give me some water.

It should be right up at the vein.

Yeah, yeah, yeah.

Yeah.

No, no, no, no.

I won't stop.

I won't stop.

Give me, give me, give me this.

I want to see the whole thing.

I want to see the whole thing.

medical training. Are they watching the operation with 3D glasses?

Yes, yes. Professor Grassi, we are here in Suzhou, China. We have an auditorium here.

Right here we have about 30 to 40 surgeons from China watching the 3D laparoscopic surgery.

Okay. Let's go.

Do you put a hemlock on them?

No, no, no, no, no.

I want to use this one.

Oh, I love it.

Although it's my first time to use it.

Wow.

Titanium clips from S-Club, yeah.

I will use the vascular stabler, yeah.

Did you have cases of pulmonary embolism due to the vascular stapler?

Yeah, good, okay, okay

Good, almost finished

You're almost finished

Okay, okay, okay

Oh, it's a branch, let's say it's a rather hepatic vein

this is the branch of the dorsal part

maybe the dorsal part of segment 8

right?

ok, your operation is almost done

and I will

switch for a few minutes

to Rome to say hello

to Professor Giuliate

oh yeah, go, go, go, it's very happy

to be with you

for the last 3 hours

I finished my operation, right?

I will be back

to you soon

英语,英语。

英语。

小心,不要痛。

Felice, can you hear me?

这时候切得很深,是不是啊?

Okay.

往这儿,往这儿。

Correct.

We still have the Chinese audio connected,

and it will be disconnected soon.

But the Chinese surgeons

We'll watch the operation

So it will be better for us

To speak English

Professor Grass

Can you hear me?

Hello

Is the organizer here in China

And because we are here

It's very late

In the evening

We have to go

Yes, okay, go ahead, disconnect your connection, that will be okay for us.

Say hi to everybody, please.

Okay, it's going to be better that the Chinese organizer will disconnect their connection.

We can say hello to Dr. Yilian.

Yes, please, we can say hi to Dr.

Can you cut the video from Italy?

Italy operating room.

Can you cut it?

Put it down.

Put it down.

Felice, Felice, Felice.

Wait a second.

Wait a second for the camera.

Because we are disconnecting from the Chinese.

There is still a bit of chaos.

Have a moment of patience.

Otherwise, we won't understand anything.

Okay, let's end it. I'm tired too.

Come on, I'll kiss your ass.

Alice, here we are.

We can go. We can also go in Italian

because they will continue to watch the operation in Chinese

and not ours.

Thank you.