F. CORCIONE

Okay, we're ready for our fourth case.

This is a case of a 66-year-old female with a BMI of 23.5

and a past medical history of HCV,

had a hernia and GERD, ischemic heart disease, and hypertension.

She has no abdominal surgical history.

Six months ago, the patient presented with blood in their stool,

And for this reason, she performed a colonoscopy, which showed unescalated lesions at 9 centimeters from the anal verge.

Biopsies were taken on these lesions, and pathology showed a moderately differentiated adenocarcinoma.

She also performed a CT scan, which was negative for a secondary lesion.

Patients underwent neoadjuvant chemoradiotherapy until October 2018.

And her most recent workup was an MRI performed three weeks ago, which still showed a thickening

of the right wall of the rectum and with a narrowing of the rectal lumen and some micro

nodules in the presacral space.

Therefore, the patient is now scheduled for a 3D laparoscopic low anterior resection of

the rectum.

Yeah, go on.

Hello, can you hear me?

Respondi.

Ciao Franco.

Ciao.

Mi senti? Sono sempre Fernando, si.

Ti volevo chiedere una cosa per mia esperienza.

Poi riprendi a parlare, perché ti seguo in inglese, soltanto che non posso intervenire.

Sei abituato a fare un'esplorazione del retto in narcosi,

whatever the height is evaluated endoscopically or with the resonance obviously if it is not 10 12

centimeters the finger so long also always in my opinion it is fundamental because there are

today different strategies and many times the endoscopist does not give the right evaluation and we are

more and more for a transanal approach when the tumor is very low and therefore the exact

in anesthesia the exact distance from the anal margin and you can really evaluate it in gynecological position

in anesthesia, it allows you to make the initial choice if to go all the way to the paroscopic or

make a mixed path, transanal and the paroscopic, but this 10 cm we have not done it.

The transanal when you do it, the TATMI, that is, the perineal time after having done it,

quasi sempre facciamo la tata cioè facciamo sì sì sì quando però c'è un'indicazione a

una stomosi ultra bassa o a una colla anale una colla anale sì che non è la TATME

perché quella dovrebbe essere fatta esclusivamente almeno in senso stretto

attraverso per via endoluminale e poi però leggiamo la letteratura una cosa se

poi sentiamo le esperienze dei chirurghi è un'altra cosa per le esattamente hai perfettamente raggiunto

sono le mode che viviamo di mode per fortuna tu hai superato questa fase da quasi trent'anni

Hello? Can you hear me? Hello, we're all here. Francesco? Yes, it's always me. Okay, so we start

So, to start with the last colorectal operation today, I decided to give you all the kind of laparoscopic procedure.

And this is the last one. Did you hear the presentation?

in order to recognize the anatomy

and stabilize his left colon

that is attached to the right colon,

the logical attachment.

So even in this case,

and overall in this case,

it's very important to recognize the anatomy.

Francesco, do you have a good vision,

a good quality of...

Yes, the image is clear.

I can see that you also identified the told fascia down there and you're opening the pre-artic plane actually

The trocar position is the same of the left hemicolectomy, but we had one trocar more

in the solar pubic area where we performed the solar pubic incision

so we need five trocars for this technique

For two reasons. First, because I need one hand more for the TMA, and second, because sometimes it's better to put the staple very, very close to the rectal section.

To do this, it's better to have a public approach.

So I immobilize the trite ligament, and this is mandatory in this case because we did not

see the basenteric vein, now it's clear, look, my goal now is to identify the anatomy, but

it's not clear in these embryological adherences, and with this adhesiolysis, and with the mobilization

Look at the vein, it is completely covered by these aderences, embryological aderences.

Now the bowel is coming out and I am able now to identify the anatomy and to start as

as before, with looking for the right plane,

right layer between all the gelato.

There is something here, I don't know what it is exactly.

It's very strange.

Lymphatic, yes, lymphatic cyst, I think.

It's not dangerous for the patient.

They need to be down.

Look, the small bowel is attached to the...

Okay, now look how is the bowel attached to the left mesocolon.

Incredible, eh?

Okay, now it's enough to start our operation.

Please, Vicky.

As usual, I go down the way.

It's very clear now the layer between, the section between the gerota and toe.

look always the same right the left always the same concept is the safe way to go ahead

if you identify this layer it's very faster and safe to go very very laterally

the traction and the contraction with the right and the left hand look it's very easy

without coagulation, without bleeding, without haemostasis, without losing our time and now

we go on the mesenteric artery, the concept is that if we identify the right iliac vessels,

We go medially, okay, medially, and wait to join this dissection with the previous one,

looking for the artery that is between these two layers.

Look, we are happy.

There are some nodes here.

and as before the best way to clip the artery is to go around the artery with

for this dissection. It's possible to mobilize posteriorly the artery. Okay the

lymphatic tissue it's always behind the artery and here there are the nerve

the parasympathic plexus. So I ask the clip. One clip is enough if you use an ultraseal.

As before, exactly as before, always the same. And now the secret to performing the right

nerve sparing technique is to leave in place the nerve, to go very, very close to the distal

part of the artery to lift and to go to dissect very very close the posterior part of the artery

leaving place all the nerves that are here in this way you are able to join the previous

dysenteric vein with the layer of the artery in any case we have around the artery

gerota so it's important that we leave a very very small part of this space without the gerota

and then we have all around gerota's fashion yes and now always with the traction and counter

traction i go medially laterally up down to mobilize as i can okay now the last step is to

Now we go to the mesenteric vein.

You can see the vein, the renal vein, yes, you are right.

Is that a left colic vein that we see as a branch there?

This is the IMV that you are isolating.

And there's a branch up there.

In this case there is no artery.

Okay, okay, now I lift the mesocolon with my left hand and I try to identify the right

dissection between the mesocolon that wraps and the pangas, then slide down.

with a lateral approach, under control, under visual control, with less risk to injure the pancreas,

with less risk to injure the mesocolon.

And now I try to reach the lesser sac from down, that we opened already before.

Okay, I reach the lesser sac, okay.

Okay, and the posterior gastric wall is there, and now, as usual, I put my sponge under the

inferior tail of the pancreas, and all in this moment, I go laterally to dissect the

left colon.

Of course, this lateral dissection is easy if you were prepared at the posterior layer,

As in this case, look, I am very fast, because I dissect very laterally, and now, as before,

I change my walker-throcker of the right hand with the wiki, wiki takes my place, here.

Always yellow, never the bowels, because of potential complications.

And I am trying to have a good disposition and with this trocar it's more easy to go

very closer to the dissection in a perpendicular way, as you can see, to finish this mobilization

of the mesocolon from the pancreas.

to do this in safer way you have always to detach completely the people on from

the transverse column and now to identify the right way thanks to the

sponge is there so this is the right way this is my landmark okay I am sure now

that the pancreas is behind the sponge so I can go without risk to damage the

pancreas, and I finish my mobilization in a safer way and faster way. Okay, anything is clear,

the pancreas is there, the genital fascia is there, the spleen is covered by the epipleur that stays

there, and now we go down, we put the spoon in the pelvis, and now we ask a turn there because we have

to mobilize better the bowel from the mesocolon. In this moment, we ask to the anesthesiologist

to have the best position, the best trendelenburg. In this case, it's mandatory because, okay,

grazie. We have this attachment for the bowel. Look, if I don't perform this adhesiolysis,

In alto, in alto, in alto.

Forte.

No, look.

How is it?

Tieni qua una troca.

Joanna, wake up.

Bipolare.

Una Giovanna che tenga.

Okay.

Lascia un po' per me.

Giovanna, pronte a lavare?

Allora, piglia qua.

Tira verso in alto.

Verso in alto.

Verso in alto.

Okay, look.

There are all these adherences that will...

Yes.

But if you go directly under the peritoneal layer,

as you can see, you have no high risk to damage the different structures.

Incredible.

Follow me, follow me.

The bowel is very, very close to the...

It's very complex.

Additions all the way down to the pelvis.

It's an embryology addition.

It's worse than a surgical addition

because you are never you never are able to understand where is the hand of this

yes

okay now clean the scope but it's very interesting I think to show this case

because it allows me the possibility to demonstrate that it is important in this case to recognize

the right anatomy, even if you lose a lot of time, because otherwise it's impossible

now we identify the Jota on this side and now everything it's it's free okay

you can go ahead Francesco not easy I think you have to work twice I mean

one for the tall girota and before that to detach the colon now he's doing now he's doing

torture but before there was another the left column was attached to the right pelvic wall yes

yes this is the reason of these difficulties

Let's see what it is.

We have a little thumb here.

Okay.

This one.

Okay, laterally.

We have a sponge inside.

Now I go in this avascular plane to complete the dissection.

Right, right.

This way.

Now it's very useful to have the...

Oh, okay.

Now a nice view of the Gerota.

You can see very well the esenteric artery coming from up.

Yes.

Now the sponge, where is the sponge?

Now I am looking for the right space

between the Gerota

The concept is always the same, but first I would like to retract the uterus in order

in order to have a good stitch for the uterus is below the trocar site closer to the pubis

sorapubic troca

And in this way I have a fixed position of the

at the same time of the

retrovaginal septum when we go down

Okay

Now we can see, we arrived to identify the Gerota fascia until the sacral promontory.

Yes.

Now we go down this way, okay, and now is Francesco.

Yes, we can see the beginning of the Valdair's fascia posteriorly, beginning of mesorectum there.

your father recognized very well is for me is to come back no no baragazzi in the past when

fernando pred prepared a video that i remember always about the total mesoletto resciso

with a simple hook like this one tme for poor surgeons

Vicky, what are you doing? Vicky, are you pushing me? Oh, my God! Vicky, you have to take it here. You don't have to let it go. No, no, above. You don't have to let it go. Excuse me. A little higher. Open it well. Hold it well and pull it well. So, let's wash it. Yes. Hommage to Fernando Prete.

Thank you so much, teacher.

You are the teacher. Now you can see very well how is the gerotofascia, how is the mesorectal fascia.

I think that this device is very useful to avoid the wrong dissection because it obliges you to go very, very slow in the avascular plane,

and now we are starting for another operation after the left

hemicolectomy, of course. There is a little bit of edema for the radiotherapy. You

follow the nerve laterally. It's very important to understand that the

mesorectal fascia is between the two layers in the woman, the valdea, and the

the rectovaginal strep in the man, valderia, and I think that is a tumor, and then we get

fascia. In this case, I prefer, I need to go very, very slow. We went very fast and

faster way until this moment. This is the fourth operation of this day. It's a big effort.

It's very useful to use this bone in the Pinot technique, as suggested by Bill Hill to Joël

Leroy during a mesorectal decision in Strasbourg many years ago, and I appreciated his way

to dissect.

I think this is a tumor, a big tumor, unfortunately.

It's a big one, yeah.

Big tumor, yes.

Yes.

Ah, but look here, don't pull here.

Yes.

No, here you have to pull down now.

You have to pull, you have to pull.

Vicky, wake up.

Vicky.

As you can see, I'm going with the blunt dissection.

Where are you?

Where are you?

Stand in line with me.

Leave it there.

You can go up a little higher.

Pass.

12.

Why I am so lucky with Vicky and Vanya and Yaya and Isabella?

Why?

I am outside of the tumor, it is there, the nerves are there.

We can see the hypogastric nerve.

correct position, yes, to identify the retrovaginal septum, that will be our guideline for the

we are doing recto vaginal septum yes

okay now i found this layer

okay now i have a good vision no no perfect

look at the nerve

are they segmented laterally

yes we can see that

now you're complete with the right lateral dissection

there are comments here that people see signs of previous radiotherapy and they're saying this is

a difficult dissection maybe not in your hands but it is a difficult dissection you see adhesions and

and edema from previous radiotherapy.

The most important operation is the parascopy with the rectal surgery,

both open robotic and the parascopy.

With the robotic there is still a problem of...

Dear Franco, lately I have used the robot for the rectum several times,

but there is still a problem of...

I don't like it.

Dissezione. No, c'è un problema ancora di divaricazione non adeguata.

Perché non riesce a divaricare?

Non si riesce a divaricare in maniera... perché non c'è la possibilità di...

Si può mettere un trocar sovra pubblico, ma è molto difficile poi da manovrare perché c'è tutti i bracci intorno.

And so I have to tell you that the field, the light that you have and the possibility of varication that you have in laparoscopy is not yet possible with the robot.

This is my opinion.

Yes, well, you know that so many things are said.

yes I believe that there is a zone of fibrosis of fibrotic edema that has fused the planes there the

the parietal pelvic band with the visceral does not have its identification anymore.

The reason why they are trying to go...

Well, what you can do easily, for the most part of us humanoid, is much more...

Yes.

We are on the Valdea, this is the last plane.

The difficulty in this case, I think, is that when we spoke about the radiotherapy,

it's the same as when we spoke about the surgery.

It means that the results are not always the same, both for oncological results and for functional results,

results, anatomical results, because it depends on the radiotherapist, from the device that

he uses, from the patient, from the tumor, a lot of variables.

perioperative endoscopy or if you have some doubt about the right location of

the tumor you need about the perioperative endoscopy. If you see very well the tumor

in the finger or if you are quite sure that you are at least two or three centimeters below the tumor, it's useless.

What do you think, Fernando?

Even in this case, I am happy because I preserved the Valdéa fascia,

so I went in the right layer of the section.

I'm a cameraman, I'm really good at it.

It's difficult to have that.

It's easy to, but I spend a lot of money for him, Fernando.

We were just saying that it's very difficult to have such a good view below the tumor,

because the tumor is also bulky.

I have something to tell you about this.

Six months ago, I organized, as often in our department, the full immersion, as you know.

And I invited Armando Melani, he's a Brazilian surgeon, an expert of colorectal surgery,

the director of IRCA Institute in Rio de Janeiro, and Jack Maresco, and the other one.

And Armando Melani performed the rectal cancer, and it was the brother of Sterex, Sterex is the cameraman, the brother who had the scope to help Armando Melani in that operation.

It was not easy and suddenly I went in the room, in the small room that we have for our

course.

It was Jacques Marescaux and he asked me, but who is the guy that helped Armando?

I told him, that's Tartaglia.

This thing is fantastic.

Fantastic. I've never seen someone who can do inspiration this way.

I would like to give him a gift.

I invite him to the next course, Colorado Course in Strasbourg.

He's my special guest.

So, Ernesto Tartaglia, from Barcaturo, went to Strasbourg.

Ah, fantastic. But now you will, after our comments, you will have to pay him more.

Like Cristiano Ronaldo.

Now I have a woman, a new explosion.

Ah, fantastic team.

Why are you standing here?

Can you see a little bit?

Okay.

Can you see a little bit here, a little bit further back?

I have no news about this Palazzini Congress.

How many people?

The room is absolutely full.

There are people standing on feet.

It's about lunchtime and now some of them have gone to lunch but still more than half of the room is still full.

So it's having a great success as a congress and actually people are coming back now so it's quite packed.

There are 12 channels and now only six are active and your one is at the top.

rectum below five centimeters the finger over Carlos Agnelli is there the virgin is there

okay we are about four centimeters at this river

Fernando?

It is hard.

Eccomi.

I have this problem now, but the tumour that you see is on the left, is outside,

side of the meserator, you can see the tip, and I have this nerve involved in this mass.

I have to sacrifice this mass.

But it seems vascular, you say.

It seems vascular, I don't think it's vascular.

Yes, it is a vascular stretch.

Yes, you are on the pelvic floor, so at that point,

even the lower pelvic floor, the lower hypogastric floor,

the pelvic floor has been lateralized.

Right, Vanya?

Something more, posteriorly.

The green one, Narayana.

I put the staple in the soca, soca, soca,

in order to arrive very, very closer to the appendicle.

No, no, aqua.

As for the...

I lost to me yes and also me not in this case so you're thinking anything else to

me I think we will try to perform all the kind of test but 45 green cartridge

Your finger, Pablo?

Ok.

Ok.

So, we...

I'm sorry, I didn't hear you.

No.

Opposition of women.

You are opposed.

Why?

You are opposed.

You are opposed.

You are opposed.

I'm making a mistake.

Look.

Don't light.

Mm-hmm.

No, no.

C'è qualcosa è andato dentro, vai.

Ecco.

Andiamo di qua.

E non ci fai vedere lo cemento.

No.

Va bene.

Andieni qua.

Andieni qua.

Ti fai da sé.

Fa per te.

Eccolo qua.

Now we'll try.

Lascia un po'.

Oh.

Lascia.

It's better now.

Lavati un po'.

C'è sporco.

Okay.

No.

No good.

Non c'è niente.

Non c'è niente.

No.

Ultracision.

Usually, you have to put only two steps, dissection, which means that you did not do a good dissection.

Let me wash it.

How much is it?

Okay.

Put the sock away.

Yes.

Let's take it off.

Pull.

Clean sock.

clean then this dissection that surely has not been beautiful in my opinion it has not been in those

scholastic but following the dictates of this surgery however we were able to preserve

you see the face of valdaire that this of course we arrived at the floor the nerves I don't know what it was

It was a very voluminous piece, I don't think I had any alternatives.

Ok, after this, let's repeat the colon as always.

Let's prepare for the mini laparotomy and for the anastomosis.

Go, de souffle, vissili, vissili.

Are you 4-5 cm from the anal margin?

with less than 4

Carlos Sanchez

has put

the little finger

and said less than 4

so I think

in the osso I can stay calm

I think so

you know what I say

I say

with age one becomes wise

the light

in the sense that

in the sense that if the patient

If the patient is well, it is clear that we are all happy, but if he is seriously ill,

in the sense that he will hardly be able to recover,

should he have an anastomosis, better a provisional one?

No, he has been irradiated.

un'anastomosi extraperitoneale ha avuto una dissezione complessa non credo che ci siano

dubbi chiaramente mi assomiglia a pasterex diretta esperto confezionamenti passo un'amica franco onde

Do not think that I have abandoned you this year, I'm always there.

Good morning.

But you arrived late.

No, dear, I'm here from 7.45.

I followed you, but the Prete family took everything here and then, among other things,

Francesco is with me, so I was present with him, you know.

you know well and I wanted to tell you that even if I share in full even let's say the wisdom that you

say that of doing a protection because you don't recover it anymore if not then that anastomosis

so let's say congratulations it was a difficult case so thank you there are we have done today we have

given free rein to the surgery of the colon I saw that what else you have in the program now we have

We have a symptom of Dunbar, the third case in my whole life, so it will be a little more fun, we will completely change the scenario.

Yes.

All right, Franco, good job, I wanted to say hello to you.

Thank you.

Yes, as always, 6-7 cm, 8 cm, they are always a fault.

Yes, but there will be 2 cm abundant of clearance of stale, right?

Look at this, what type of vascularization, because this was practically the adhesion that we had to use.

And the vein here, who knows where it ends up?

Down there.

Okay, now we have it here.

Okay, then,

a lot down,

so here,

the utracisia.

It was difficult for you

from the beginning,

because you couldn't understand where the plans were.

It's a congenital situation

that can be found sometimes.

But it was nice for me

It's a pleasure to show how you don't have to lose the compass, because there are those cases where if you lose the compass you find yourself really off-road.

And then you don't find the road anymore.

could have given the right message.

It is what many see in one year in their hospital.

I don't know if I have to speak English.

I've not heard any comments in English so far, so Italian is fine, I guess.

Unless somebody from outside wants to comment in English.

Performing for colorectal operation, one after another one.

see any kind of surgery done with different approach, different strategy and this is the

And the reason for today is for operation colitis surgery because I think it's a good way to live,

to see always the same anatomy and to receive the same messages from different fields.

Right, right, from the epithelial side.

It is a bit difficult to keep in mind all the things that you have to change

when you face benign pathology and malignant pathology on the right and on the left.

And you just presented them all at once, so we could make a comparison.

So if you ask to, I think, ten expert sergeants, which one,

and you ask what is the technique for the diverticulites,

you will have ten different answers.

That's true, that's true.

Guys, I'll leave it here.

Let me wash it.

Clean.

It's very, you want to suppose, but it's very,

It's very, without tension, to wash.

Is there a chair inside?

Someone lift the plate.

Here.

Let's remove the chair, please.

Let's remove it.

Okay.

Okay.

Go.

Go.

Carlo.

No, this one.

How do you say?

The vagina.

The vagina.

Lift the vagina.

Lift the vagina.

Okay.

Carlo, the other side.

No.

No.

No.

No.

Yes, yes, no, I'm here.

No, it's that the point from the uterus has been detached and the vagina has fallen forward.

Yes, it always detaches when you do the mini-lapotomy.

And this is to move the vagina when the anastomosis is very low, it is very important because the genesis of the colovaginal fistulas, post-rectal surgery, is often determined by involvement with the stapler, metallic points that decubit.

Yes, now the distance is clearly visible.

Press Uppra, check the penia, OK, close the window, here.

You see, a single clip on the Ami root.

It's gone.

In any case, we perform the test.

so much, thank you so much.

So I, if you agree, I will leave a...

Is it a hydro-pneumatic test or a blood-methylene test?

It's negative, but in any case I prefer to hear from Ariostomi.

And I will leave Sterex, the specialist of Ariostomi,

and I will go to drink a coffee before the last operation.

Thank you for your attention.

Thank you very much, Franco, from the whole room.

di quei pochi che mi guardano no no no non sono pochi però molti saranno delusi quando

cercheranno di fare le stesse cose vedranno che sono molto più complesse di nella tua facilità

ciao grazie