Prof. JIHUI HAO Pancreaticoduodenectomy

You are the president of Tianjin Medical University Institute on Cancer Hospitals.

Yeah, yeah, yeah.

Executive director of China Anti-Cancer Association

and president of Tianjin Anti-Cancer Association.

You have been elected as a chairman in Cancer Precision Treatment Professional Committee,

Vice Chairman of Pancreatic Cancer Professional Committee,

Vice Chairman of Epidermal Pancreatic Surgery Professional Committee.

It's definitely an overwhelming curriculum with the professor, so many prizes and so many papers.

It's really an honor to speak to you and to have you in our yearly congress.

Yeah, so today I'm also very glad to attend this conference.

The operator would be Professor Ji Huihao, president of our hospital.

Okay, can you see my PowerPoint for the case report of today's operation?

Yes, definitely.

Okay, so this patient is a local people in Tianjin, 66 years male, admitted on November 23, 2022.

The treatment complaint of this patient is epigastric distension for minor ones that

cover pancreatic mass at the local hospital by ultrasound.

The patient has hypertension for 10 years, hyperlipidemia for 10 years, and both of these

diseases are controlled by the medical treatment and the control well.

This patient has no injury or surgery before.

The patient has smoked for 30 years and quit smoking for 15 years.

For the lab examination for this patient, we found hemoglobin of this patient is about

126, a little bit lower than the standard, and the liver function, the catting function

for this patient is normal.

The coagulation function of this patient is a bit abnormal, the FBG is 4.98 grams per

liter, and the D-dimer is 857.12 nanograms per milliliter.

The tumor marker of this patient is specially the C109, the CA, and the leptin.

The patient had pancreatitis before operation, the blood amylase of which is 267 uL per liter,

and the blood lipid is nearly 2,000.

Let's see the imaging results with this patient.

Here the upper one is the actual face and the lower one is the venous face.

From that, we can see the mass located at the head of the pancreas, and about 3 centimeters by 2.7 centimeters,

which is adjacent to the SMV, also the GDA.

I think this is a resectal case.

And the surgical plan for this patient is a pancreas duodenectomy.

We can find tumor-related inflammation before operation, and also the dilation of pancreas ducts could be found.

but no dilation of valoducts, that means that there is no obstructive jaundice for the patient.

But we found the landmarks of vessels for the patient, no abnormal vessels derived from SMA or CTA.

And the strategy, basically the strategy for today's operation is the extended pancreatal duodenectomy with SMD3.

And we would adopt an artery-first approach.

definitely so now we are opened uh cohort for uh procedure that is the cohort maneuver

on the left side of the picture is the professor how and the right side is the first assistant

professor gaul for more department and the second assistant for today's operation professor

Professor Zhao, also a servant for a multi-parties.

Thank you Professor Sun and Professor Zhao to be with us.

And I'd like just to get to know some of Professor Zhao's achievements.

And he's a speciality here in Papua New York.

Professor Scottizzi, Amnesty for Operations.

Can you see that? Good? Okay, good.

I'm looking forward for all the questions from you, and I'd be glad to answer it.

So now we are open to the backside of the duodenum, that is called the cohort procedure.

Actually here in the Oral Center, we always perform a cataract manual, that means an extended

this cohort procedure, which could reveal both the left renal wing and the right renal artery.

Here we would also design the number 16 nifenol. So at the start of our operation, I've briefly

introduced the strategy and the process for Professor Hao's pancreas duodenectomy. So we

We insist the principle for no back and the easy first.

Well, I'm going to do that to me.

So the whole operation would be divided into three parts.

The first one is the floor and the evaluation.

And the second part is the removal of the specimen and the deceptive lymphoma.

The third part is the reconstruct of the alimentary tract.

so when we open the cohort procedure we would that would be part of the explore and evaluation

for the tumor so today we use a midline decision uh for operation actually or center some surgeons

also adopted mid pyramid line rice para midline incision or subcodes subcostal incision but we

found that midline incision may be the best choice because it's very good for the exposure of the

portal helen also the lymph nodes around sma and smv so for extended lymph node dissection

also the reconstruction of the portal vein and smv would be very convenient also it's very good

convenient for us to close the abdomen and show advantage in injury control so here today we use

use a pair of retractors to facilitate

or exposure at both sides of the arch of ribs.

Now, Professor Hao has opened the anterior

layer of transverse colon. Actually, here, the aim of

this process is to review the whole

pancreatic head, and we could

directly evaluate the resectability of this tumor.

Some surgeons would like to open the gastrocollic ligament, but if we take this step, if we

use the approach for anterior layer of transverse colon, we could reach the pancreatic capsular

and finish so-called borsectomy, that's better for radical resection.

Okay, here the COHO procedure and the anterior layer of the transverse colon has connected.

Professor Gao is lifting the duodenum and Professor Gao is taking down the hepatic fracture.

Now we nearly came to the third segment of duodenum.

Here is the bleeding maybe due to the part of the hyaluron trunk.

that is the ASPDV or the SRCV, that is the superior red colic vein.

Actually when we are making the coho procedure, if you leave the duodenum too

far, the hyaline tract, some branches from the hyaline tract will be lacerated.

This part is easy to be lacerated during the opening of the anterior lobe of the transverse

colon.

As well as after we cut off this vessel, the transverse colon and the hepatic flexor of

the colon would be distended, continuing to open the gastro-colonic ligament.

So this patient has some inflammation around the pancreas due to the tumor, due to the

obstruction of the pancreatic duct.

So that would be a little difficult for us to reveal the whole pancreatic head.

This is the transverse colon and the anterior layer of it.

By this step, we could reach the anterior wall and also reveal the anterior wall of

SME here.

The tissue of this patient is a little bit fractured due to the inflammation.

So, during this step, there will be some little hemorrhage and just a simple location we can

explore.

Here we can see that Professor Hao is using an electric coterie combined with a harmonic

base.

So, we are looking forward to the operation.

So, during this step, I will introduce our center briefly.

Actually, our department was built in 2008 by Professor Hao.

He used to be our leader of our department surgical team.

So at the first five years, we mainly focused on the surgery, and during this five, three,

four years, people will say invasive surgery, including the laparoscopic pancreatic duodenal

anatomy, distal pancreatectomy, and also the da Vinci-assisted robotic pancreatectomy.

But we still hold the principle as the tumor biology is the first consideration.

duration, and then technically the second. So now nearly 40% of the surgery, nearly 60%

of the malignant tumor, they still use the open surgery, lateral resection.

Well, actually in China, the study group of the pancreatic surgery, they have made a consensus

toward the laparoscopic surgery of pancreas, and thus also the work principle for microinvasive

But personally, I think that microinvasive surgery and open surgery are not separated.

With microinvasive surgery, we could see more details for the natal structure for certain

vessels and organs, especially the vessels and nerves around the pancreas.

That would be very helpful in open surgery.

And open surgery is the best support for the microinvasive surgery, because in our center,

when we perform microinvasive surgery for pancreatectomy, the surgeons are required

to have to ask you for extra open surgery before the equal form that

responded or the pitch is that it's perfect now we reach the anterior wall

of the SME here because of the information the field here the vision

here maybe that's clear and help you to review the material wall of superior

message with just at the top the superior level of nearly nearly review

which is gastric vein, ASPDV, and also the superior right, very careful review of this

space.

Because of the obstructive of the pulmonary duct by the tumor, there are very severe inflammation

here.

So we will take some time to open this space and review the SMV clearly.

The trick is we should make the mobilization from the digital part, rather than just underneath

the blood vessels.

We see some bruises from the shoulder joints, sometimes maybe the operator or the assistant

will block the camera and we will adjust this camera to the operation field as soon as possible.

So considering the inflammation is very severe, we would not rebuild the SMV from the root

of it.

So actually still here, we are still at the step for evaluation.

Maybe the tunnel we built between the pancreas and the SMV for this patient would be a little

bit difficult but we can see that the cooperation between the assistants and the operator is very

good both of the first step suction parameters would help the professor how to review that space

so we could see the inflammation here is very severe so that's why we do not choose

laparoscopic surgery for this patient and here we include three principles to judge whether the

the patient is suitable, is proper for laparoscopic or open surgery.

Here we can see maybe the mid-colonial vein or the superior right collar vein.

After we cut down it, the transverse colon would be descended and we could reveal the

capillary head more clearly.

But this kind of method, we would use the double ligation for both sides, both the premium

This is a very tough note, so maybe there is a block of the camera, I apologize for that.

After the cut-off of this little wing, you can see the major part of SMV here.

That would cause hemorrhage during the dissection of this mesentery.

This is the distal part of the SMA here.

This patient, we would have adopted the artery first, so we should cut off some little branches

derived from that to make the review of the SMA more convenient.

Here we could find some lymph nodes around the SMV.

We could apply the number 14 leaf node and some of it around the mid colic wave.

Here we revealed the root of the hyaline trunk.

We could find a little branch of pyrroline with the hyaline trunk and the drainage into

the SM week here.

So here we will not cut off the hyaline trunk at this level.

Before that we will cut off the gastric by removing the distal part of the gastric.

the dissection of the leaf node around the number 8 in the upper area of the pancreas would be

widely convenient and here I should explain that there are two ways to cut off the gastric. Some

surgeons perform a PPPT that is a palliary preserved papillary adenotomy and then the

distal part of the gastric would be preserved also the palliary would be preserved and then

and would perform the duty of the adrenals though.

But for this patient, number five and number eight

lymph nodes are suspected to be positive.

And also due to the inflammation,

the anterior wall of the pancreas they had,

we would not perform PB PD,

but just standard PD for this patient.

You could cut off nearly one half of the gastric.

Here, some surgeons hold the opinion

that if we cut off more gastric

and preserve a smaller gastric,

that would avoid the occurrence of DGE here in a gastroenterologist.

But here, personally, I guess there may be a potential mechanism for this theory.

Well, some colleagues told me that there may be some activation nerve fiber

located at the lesser curvature of the gastric,

while with some certain inhibition nerve fiber located at the greater curvature.

So if you preserve a big gastric and dissect the number one, the number three lymph node

dissection around the lesser curvature, the more inhibited nerve would be preserved, while

more activated nerve would be removed.

And then that would lead to delayed gastric emptying after operation.

But this mechanism needs to be proved in many models, this is just a personal guess.

Here, Professor Hao entered the arch of the greater curvature of the gastric.

Here we would use a linear cutter to cut off the gastric.

Here we would open the space between the gastric and the pancreas, and the descending branch

from the left gastric artery would be cut off, but the major branch for the left gastric

artery would be preserved.

We can see that the inflammation around the pancreas is very severe.

Just a slight touch of it would cause hemorrhage here.

But we should not be worried about this.

Just in that culture we can solve this problem.

Here Professor Hao will also remove the capsule of the pancreas to make sure that the margin

of the pancreas, that the neck of the pancreas would be negative.

For any operation, the margin for specimen is very important.

Here if I remove the capsular of the paramedic head, we think that the neck of the pancreas,

that margin will be negative.

Considering the location of the patient, of the tumor in the head of the pancreas, we

would cut off the pancreas from the neck of the pancreas.

Also the pancreas duct of the patient is dilated.

So I think that during the cut-off of the pancreas, we could find the remnants of the pancreatic ducts to make sure our anastomosis is more safe for modifying Blancard's pancreatic ejection of the stones.

Here we came to the roots of the left gastric artery, and we could also see the coronary vein, that is also named as the left gastric vein.

Here, Professor Hao always suggests us to cut along with the left gastric vein to avoid more bleeding from it.

Sometimes, I think the colon vein could be resected.

Now we came to Professor Hao's need to remove the gallbladder for this vision

because the bile duct is not obstructed by the tumor, so there is no dilation for the bile duct.

Also, the size of the gallbladder is normal.

This patient has no history of alcohol intake, so we can see that the liver quality is very good, no cirrhosis around the liver.

And for this kind of liver, the removal of the gallbladder will be very smooth and will cause less bleeding.

Here Professor Hao found the space between the cirrhosis of the gallbladder and the liver.

Then there will be no bleeding during this procedure.

Just like the laparoscopic polytectomy, we also use the electrical cautery for the separation.

In this laparoscopic surgery, we would use an electrical hook.

It's almost the same, but this tension between the gallbladder and the liver is very important.

So now Professor Gao is lifting up the gallbladder with a forcep.

there will always be a little branch here derived from the right hepatic artery and the

dreamer gene to the gallbladder. So here that's how you select power 3 for the hemorrhage of that

little branch. Here we almost get to the roots of the the neck of the gallbladder and here you

see the gallbladder artery derived from the right hepatic artery. From now on the number

the bile duct could be reviewed and the lymph node would be removed along with the gallbladder

at the unblocked reception.

He came to the neck of the gallbladder and here we could find the gallbladder triangle

composed by the liver and the hepatic duct, also the neck of the gallbladder.

Here we could find the gallbladder artery.

You can see that the attention is very important in an open surgery.

The assistant always makes good space for Professor Hao to find this space.

You can see our suction apparatus is very good.

That's a hard one, and you could use it as nearly like a forceps to find the space.

So this is the gallbladder artery.

You are from the right hepatic artery.

That's how we use a force at this angle to make a good ligation of that artery.

Here we use for principle, in our department we have 80% and 20% principle.

So you can see the space is sure for you to use electric cautery or electric tools to

open.

You just open 80% of it and leave 20% of it as preserved, then that does not cause hemorrhage

which will open potential vessels around the organs that you want to remove because of

inflammation of this patient is very severe, so Professor Hao used an electric cautery

combined with amongst the aids to find food space and for hemostasis and now we are trying

to find the gallbladder duct.

So this patient is not myriad, it's syndrome, so the gallbladder duct will be not very long

that is not parallel with the co-bladder duct. We use a 3-0 thread for the ligation for this

size of duct. Here we will not remove the co-bladder along with the whole specimen,

we just remove the co-bladder separately because that would help us make the process of removing

the co-bladder more convenient. Here we remove the co-bladder to make the ligation of the co-bladder

duct. Sometimes we would cut off the hepatic duct at the lower part, the lower level of our

gallbladder ducts. Sometimes when we considering there are number eight and number 12 lymph node

metastasis, the cutoff margin of this would be pretty high even at the bell junction of the

left and right hepatic ducts. Now Professor Kehao would use the ammonia base for the

the dissection of the portal helm, it opened the lesser omentum and the first branch we

would see, the first vessel we would see here is the right gastric way.

If I cut off the right gastric way and the artery, we would see the fenomenal hepatic

artery and then after we remove the number 8 lymph node, we should see the hominid hepatic

artery.

And now we could see the right gastric artery, also the phenomenal hepatic artery.

I opened the soft tissue around the protohelium.

and review the left and the right hepatic artery.

Here the lesser omissions along with the protohelium and soft tissue

will all be removed and blocked.

here in this part we should keep in mind that the accessory left hepatic artery may be

listed here but for this patient there is not abdominal or abnormal left hepatic artery here

so we will open this space directly. So now we came to the number 8 lymph node. Professor Hao will try to use the

harmonic ACE to open the anterior wall of the number 8 lymph node. In oral center we still hold the principle

for the n-block in section for all the lymph nodes with regard to every

lymph node that we want to be dissected as a positive one so we not use

homogenase or electric cautery to open it. We would keep sure that every lymph node is removed from the operation field is

complete. Well we try best not to use electric cautery to open the lymph node

because that would cause and also have a risk for the tumors needing a run or operation period.

Inflammation here around the number 8 lymph node is very severe so that would be a little difficult

to dissect that lymph node so now professor has planned to cut off the gastric and to make the

dissection of the number 8 lymph node more convenient and the exposure will be very good

after we remove the distal part of the gastric. The descending branch of the left gastric artery

And we could preserve the major branch of that gastric artery.

And doing this, we could also remove the number three lymph node along with the lateral curvature.

That dissection may be not necessary for every case, but for this case, I think that dissection

would be of great importance, because before the operation, we could find a lot in this

area.

Maybe it's not a positive result, maybe, but during operation, we should remove it.

Now we can see the gastric wall here.

If we could find the space between the soft tissue and the left gastric vein and artery

along with the gastric wall, we could go along with the gastric wall with our electric artery

to avoid more bleeding.

then total location with a 3-0 or 2-0 strap that would be not also we could do

also use Camelot to make what is the location more conform this base

location so now we are at the last curvature of the gastric and to avoid

the bleeding of the lateral gastric artery it will go along with the gastric

wall and to make the soft tissue along with the left gastric vein together. If we go along with

this space, we could go to the right diaphragm and we could see the left diaphragm. The right

diaphragm derives sometimes from ciliac trance, sometimes from the left gastric artery. But we

do not cut off this artery during the abdomen. That's for REMS. That's the radical antebrae

We will cut out the diaphragm artery during the dissection of the left adrenal gland.

So now you can see that number three lymph nodes along with left gastric artery descending

branch could all be dissected and blocked along with the soft tissue at the lesser curvature.

Professor Hao is making lymph node dissection around the number eight and number three lymph

nodes around the lesser curvature.

Let's see whether the left gastric artery of this patient could be preserved, just cut

off.

Sometimes if the left gastric artery is aborted by the certain lymph nodes, it will also be

cut off.

So this is left gastric vein.

That is the coronary vein.

Also the required, we just referred to, that is the left gastric vein, also named as coronary

vein.

We would remove the number one and the number three lymph nodes along with the left gastric

eight lymph nodes would be very difficult.

For some normal cases, there would be a natural space between the number eight lymph nodes

and the pancreas.

But for this patient, the inflammatory combined the number eight lymph nodes along with the

arterial surface of the pancreas, very tight junction.

So maybe we could use here the H8 lymph node could be divided into the posterior lymph

node.

The posterior lymph nodes sometimes are very tight to the left wall of the portal.

Different surgeons have different habits.

we could see different surgeons have different habits. You could see that

Professor Hao before he used the tweezers in his left hand. Some surgeons would use

different habits. Both of them have the advantage in the left gastric artery.

It is difficult to preserve it if you want to remove number one to three

So we would cut off it.

I think that the cut off of the gastric artery would be no problem for the restosis of the

gastric artery operation.

We still have short gastric artery and posterior gastric artery for the blood cell line.

So there would be no problem.

You can see the retractor here located at the subcostal rib and this retractor is brought

back by a professor from Japan.

from Japan. We made several similar retractors in our country and I think that's very convenient

for exposure for open surgery. I'm going to do the anatomy, this is the patectomy and so on. The

remnants of the left ventricle artery. Of it, the number seven lymph node could be the remnant of

will be a little difficult and maybe there will be some block of the camera here with the readjusting

very deep very deep vision very difficult exposures but here we perform an unblocked

section of the number three and the number seven you know the nympho-denectomy during this area is

finished so for this region we cut off the gastric artery and then we will cut off the gastric

with linear cutters. This is a 60 mm linear cutter, so we use two of it. One for the greater

curvature, the other for the lesser curvature. You see that the linear cutter is very good

for hemostasis here. The lesser curvature, make sure that the cut will go along with

one geodatami, the remnants of the gut tree will be preserved here, and then number 8

the lymph node could be deceptive here. The vision would be better than if the gastric is not cut off.

So how do you try to find a good space between the number 8 lymph node and the pancreas?

Here we should be aware that the dorsal pancreatic artery derives from the homohepatic artery.

Sometimes it may go along with the number 8. First I try to find the space to make the

tunnel between the pancreas and the neck. It's a little bit difficult due to the

deeper layer. We will find the artery here. Let's see whether it is the

common hepatic artery or the actual duodenal artery. Here we could find some

some landmark of the vessels here to judge whether that is GDA or C-G.

The number 8 lymph node is a little bit lifted up.

is also necessary for this patient to make the tunnel between the neck and the back.

Actually here we are really curious about the varicose inflammation here is so severe for some cases.

Take the total opinion that the inflammation is due to the tumor itself.

It caused the obstruction of the premeditated duct and it caused related inflammation.

See the, that is the bile duct and the update is the fenomenal hepatic artery.

Maybe Professor Hao will try to cut off the bile duct here.

We use the ligation for the distal segment of the bile duct to avoid the pollution of

the bile juice.

Actually here, when we cut off the bell duct, we should be aware of the replaced hepatic artery or accessory of the hepatic artery.

Sometimes the replaced hepatic artery could derive from the pure mesenteric artery,

and then go along with the back side and the anterior side.

But for this patient, we don't find any replaced hepatic artery here, so we would cut off the bell duct directly.

directly. Let's re-bell that. Two sides, left side and right side, there are two sides of

the bell ducts we can find the blood supply here. Actually we find, we call it three o'clock

and nine o'clock hemorrhage point. I think that the blood vessel here is very consistent,

very consistent. So here we will use a ligation to avoid the blood bleeding here and when

When we performed the cholangioid adrenals domain, we will open it again.

Now we can see the number 12 lymph nodes along the portal vein.

At the right side of the portal vein and at the back side of the bile duct,

we find the soft tissue of this patient is very sick due to the inflammation.

For some patients who performed a few of the peritoneal trans-hepatic cholangioid drainage,

the inflammation around the bile duct would be more severe.

But for this patient, we don't have PDCD due to the pancreatitis, the information here

is new virus here, but much better than the patient with PDCD here.

So we remove the number 12 lymph nodes, we can find a little branch here derived from

the photoin, the number 12 lymph nodes, and the superior pylori region.

By doing this, we could remove the number 5 lymph nodes along with the number 12 lymph

nodes at the upper area or region of the country.

This is the portal vein we could find here, the right wall of the portal vein.

Just I referred to replace hepatic artery.

For this patient, we don't find that artery here.

There are only portal vein.

Almost we find gastrodendron artery here.

Actually, Professor Hao, before he cut off the gastrodendron artery,

the right hepatic artery would always be found around the portal vein.

Because some replace the accessory, it's like you have to upgrade your dino.

You find the little branch derived from the GBA.

You can make the suture with 4-0 barring for hemostasis.

You see that the tissue here is very, even the suture is very difficult.

I think that the suture here is very necessary.

Some surgeons don't like to perform suture at specimen size,

But I think that the one more time of reach and also make our space more clear

Silt here is very necessary. That's a 4-0 crawling thread. The top tissue here is very tight to find a

natural space here. Actually for some patients with no hepatitis, the space here is very soft

The review of the gastrododinoid is not that difficult. That's here is the bleeding

So ligation would be right here.

soft tissue here.

We almost see it under the haemolysis here.

That is the GDA, I think.

Or maybe that is the root of the GDA, and maybe that is from the hepatic artery or gastro.

So sometimes sharp isolation is also necessary for this kind of cases.

So we have to see the conjunction of the common hepatic artery,

phenomenal hepatic artery, and also the gastric adeno artery.

Actually, the operation for this kind of pancreatic cancer patient with pancreatitis is always tough.

So this is not an easy case, but a very example for us to show how to handle this

of the inflammatory tissue around the tumor and how to mobilize the GDA.

Dr. Hao told us that GDA is partially invaded by the tumor.

So that would be cut off from the root of it because for us to make the location of the GDA here.

So we are looking forward to the situation of the GDA here.

so maybe more space at the right side. Fortunately this patient don't have DPA

here so we could use the forceps to make a space. If we can't find a

such space, then we make space. Okay, Professor, I have found a space for the GDA and let's

see how to manage the remnants of the GDA here. Actually to cut off the GDA is the most

dangerous process during the whole cathodotectomy.

Sometimes we make nodes here, sometimes we use the hemlock

and also use 4-0 to 5-0 formula to suture them

to make the remnants of the GDA long enough to make the remnants of the GDA

long enough to be very meaningful. During the operation the cut of the GDA

will be very safe and after that if we perform an

intervention for hematophysis of the remnant of the

GDA then there would be more space for us to put a stent.

we've used double ligation at the preserve side of the GDA. Sometimes the

remnant of it would be, we would preserve five to six millimeter GDA. There

must be some enough space for the two ligations. Make sure that we can see that

from above to make another ligation here. And I think both of them are 3-0

Under the forceps, it's a complete tumor.

So now here we use a 3-0 porting for the distal part of the GDA to avoid bleeding here.

The suture here would be a good option because another ligation, there are not so many spaces.

The suture here would be very deep.

Make sure that the distal part of the GDA is ligated.

In normal cases, we would put another ligation and just use the hemlock and the distal part

of the GDA.

But here, we use a 3-0 poly to make sure the cut of the GDA is safe enough.

So let's wait for the cut of the GDA here.

To avoid the bleeding of the GDA, we use a forcep to make another ligation.

That means we will make three times of ligation at the preserved part of the GDA here.

We will not put much more pressure here and we use a stop cutoff of the GDA here.

It's okay.

We'll make another suture after we cut off the GDA.

After we cut off the GDA, the blood supply of the capillate head is being cut off.

And that's when we cut off the IPDA, that's the inferior peripatetic actitudinal artery.

then the total blood supply for the artery system would be carbonation here.

I guess that is the distal part of the GDA here. The specimen side has been filtered

and very safe. Another filter for the remnants of the GDA here.

We have three legations at the preserved side of the GDA. That would be more safe than just

GDA totally.

Some surgeons hold the opinion that the GDA is very, they take a very big chance around

the whole artery.

For the suture here, we should make sure that the whole layer of the GDA is sutured.

Full ligation, one continuous suture.

After we cut it down, I think it's time for us to cut the pancreas, make the tunnel.

So considering the location of the head of the cartilage, the inflammation here is very

severe.

For some neo-Jewish cases, especially the tumor located in this similar place, after

the neo-Jewish chemotherapy, the dissection process here will be more difficult than this.

But for this case, I think it's difficult enough for us.

So the truth of the patient is very good.

I don't think this is a case like progress or like a little branch derived

from the homeostatic artery yes it's a SPDA or PIPDA training to

find a little artery branch you are from the nominal legate here

the distal part of it, to cut it up, to create a tumor, so try to open the shaft of the artery

to make sure the margin of this is active, so it's difficult to make a channel, to make

a tunnel.

By Qianbing, we find that the portal web completes maybe just the right wall, not the whole of

it, just a part of it, here is the space, the region of the piece here is building up,

Actually, there is no sagittal direction derived from the photo wave.

It's safe for us to use the bursa to make a space between them.

The bursa is not long enough to reach the upper region of it.

We change a bigger one to try to make that space.

We'll find that space and the ligation will be made on the proximal side.

Our suture will be used in the upper region.

used for the exposure. You can see that the quality of the pelvis is very, even the suture

cut off the pelvis. We use electric cauterate to cut off it. The pelvic duct of the patient

they located that the inflammation in pancreas was very severe. Due to the filter, we could find

nearly no hemorrhage during this process. In Japan, they also used the scalpel to cut off the

pancreas directly, but that would cause more hemorrhage. I don't think that's a good idea.

I think that lacricottery could be used around the pancreas duct because of how many use

So you plan to find the pancreas duct? You help us to find the pancreas duct?

Yeah, remember to notice us when you find it. We all stare at that place.

I'm sorry, I think you were somehow alone during this period, but it looks like I'm using

a platform, and I've been told that the two discussants are using a different one,

Yeah, we can use the Zoom for discussion. Yeah, we could put questions here. Either Zoom or Tencent is okay here.

Yeah, we have some, yeah, find the branch here from the photo way.

You already put a stitch over there, but it looks like you need another one.

Yeah. So, by the way, I wonder how you cut off the pancreas in Italian when you perform

duodenectomy. Do you use an electric cautery or harmonica or just a scalpel?

You just took out the question from my tongue because I was just going into this topic.

Normally we use, we often use somehow, sometimes a suture, or just a, how we call it in Italy, a cold knife, I mean a scalpel.

Not here. Oh, it's not. Sorry, due to the internet, there is some lag during your answer.

I think due to the hard quality of the pancreas, I think it's very difficult to cut it off.

But during the anastomosis, we like this kind of pancreas rather than the soft pancreas.

I think we have got to the pancreas depth.

We almost got there.

After we opened this layer, we could find the pancreas depth just under this layer.

We have found it.

That's the pancreas depth.

and we built a whole interior wall of the photovoltaic duct here.

It still has a branch at the lower part of the pancreas derived from the photovoltaic

duct.

Actually, we call this kind of vessel a gateway vessel, just almost like a short plastic wing.

We could call it a short pancreas wing, maybe.

There are many branches that are from the portal vein like this.

So you should be very careful when you cut off the pancreas and also take along the lower

part of the pancreas.

It will cause hemorrhage if you make that cut off.

We can see that the right wall of the portal vein adheres to the pancreas and the acetyl

presides very tightly.

But I think there is a space here.

The information here is very tight.

I think that this one is great. Just center it, and it's okay.

Okay, okay.

Now it's really clear. Perfect.

If there are any other requirements, just inform me immediately. I can zoom in and out.

So this is the Helen track, I think.

Yes, in the beginning I was just somehow shy to speak to you,

because i really didn't know if there was some discussion in another platform and i couldn't get

it okay i'm waiting for that i'm looking forward to any questions actually yeah if there would be

more discussion during the operation that would be more fun or interesting here now we are legacy

the highland trunk here from the root of this after this the only conjunction part of the smv

the acidity process. But we will not manage that part in this section. After we cut off

the GI adrenals, then we would try to cut off the acidity process. We can see that the inflammation

of the patient is so severe that every ligation and the cutoff of important vessels here is

very difficult. We don't have much more space here. Make sure the remnant part of the helitrans

It's conformed. Professor Hao is using a scapula to cut it off at the removed side.

All of these remnants will use hemlock to reinforce that after the removal of the specimen.

And the suture for the top side of the hematrach along with the neck of the pancreas.

I think that the hemostasis for the specimen is as important as the preserved side.

to make our operation field clean is of great importance, especially for the top case.

I think we need another filter. Due to the IPDA of the patient is still preserved here,

so the blood supply of the whole pancreatic head is still very rich,

so the reflux of the SMV here would cause bleeding, so another filter is needed.

PIDV, another ASPDV or PDGV derived from the SMV for the drainage of the acidity process

before we went to the Jaguno part to make another filter here.

Actually there are only one branch from this, that is Highland Transport.

Sometimes we can find ASPDV from it.

also we call the PSTV as a voucher branch during the process of during the

removal of the company they had as a good fight to the g1 the first branch of

g1 are with or to our options you are proud with that we go along with the

arsenal process the g1 way I think it could be preserved that you know as mp3

That is the third level for the superior mesentery intersection here.

But sometimes G1 atlas way and atlas would also be separate.

We came to the lower part of the, and this is the tris-legament.

After we open the tris-legament, and we can see the IMV, the inferior mesentery way here.

The inferior mesentery way is reserved in this case, to open the tris-legament completely

completely to direct the proximal jejunum to the left part, from the left to the right.

Now we try to, this is the proximal part of the jejunum, that's removed to open the

mesentery of it first. This part, which is the wall, is bleeding from the mesentery.

So this patient, we don't find the number 14 lymph nodes that are suspected for operation

So we would preserve some of the mesentery here and just remove the proximal jejunum along with the mesentery.

Here we could use the diacal clostridium for this part of the little veins.

Most of the little branch here derived from the G1, the first branch of the G1 vein.

and some of it are from the G1 actuator that you know where this cases could be

reserved that's way too soon for one hour and a half we have got nearly 60% of this case

that I mean the remove part also we do have 15 more minutes for the

prospect of the elementary trap for punctured adrenostomy, manual adrenostomy and gastro adrenostomy

Here we will use another 60 mm linear cutter to cut off the jejunum on the mesentery side.

Another location here is needed.

Before the angular jejunum is done, we will make a continuous filter here

to reinforce the remnants of the jejunum.

You can see that we use a pin for that here.

We lift it to the left side,

and then Professor Howe would open the mesentery of the Proximo Geogenomist in a harmonic ace.

Most of the little branch could be cut off in this way.

The big branch here we would make a legation or even a suture.

And we see the left hand of Professor Howe trying to hide the G1 artery and the G1 wave in his left hand

to avoid bleeding, and it's cut off, and we would cut it off by chance.

side of the SMA. Here, although we don't open the shaft of the SMA here, you can see that the SMA goes along with the mid-colonial vein.

Because the portal vein is not weighted totally by the patient and the reconstruction of the SMA and the portal vein is not necessary for this patient,

So the climb, actually first branch, is not so necessary for the patient to perform, weighing

first branch.

Okay?

Now the proximal jet genome could be drafted to the right side, and the only part we left

for the V and SMA is the acidity process.

Tumor is not located at the acidity process, so at this point, more safe and happy for

us to make that separation.

still we should make sure the G1 wave and G1 atrium could be preserved and we could see

whether the IPDA is derived from G1A or separated from SMA directly. I think for this patient we have

only one IPDA. The variation of IPDA and G1A are common in this part. Sometimes we have one, two, three

You can see that during the first step of the regeneration, we find that maybe the right

anterior wall is invaded by the tumor.

Now with this step, after we drag up the genome from the left side to the right side, we can

see that the right wall of SMV is completed.

Now under the suction apparatus, we can see the SMA, that's the right side of the SMA.

Now we can also see the G1V goes along from the right side to the left side.

Yeah, that's the G1V. Maybe there's an IPDV derived from it.

Let's see whether Professor Hao would preserve the G1V or cut it down.

Now the number 14 lymph nodes go along with the specimen as another N-block infection.

So now the vessel we located is IPTV derived from G1V.

Now the only big vessel could be named is only left is IPTA, I think.

We found the IPDA here derived from the SMA, I think directly, not from G1A maybe.

It's really big, it's a very big artery, I think the size of it is nearly one centimeter.

So before we cut it off, we could make the acetyl peroxide layer thinner.

I think that the good space for the management of the acetyl peroxide is from layering, not

vertical.

You could make it horizontal, open the layer horizontally, one layer by one layer, but not go too deep, vertical side.

Even with laparoscopic pancreas duodenatomy, this part, we open it layer by layer, and we don't go too far in one stage.

We can see that when we cut off the pancreas, we found that the right wall of the photovein

is invaded.

Now we can see the boundary of it.

That's IBDA.

We will make a navigation here.

IBDA is a very deep node, so sometimes the camera will be separated from the SMA directly.

So by doing this, I think that the blood supply to the whole specimen has been cut off.

The thing we need to do here is just to remove the specimen like a coterie, layer by layer.

And this thing, this process would be very happy, no danger at all.

But we should still consider about the right wall of the motorway here.

Maybe it's invaded, but I think, yeah, this is the PIPDV, sorry, PSPDV, and we call it

the Belcher here.

Maybe it's Belcher.

So just like I told you just before, when we do this part layer by layer, rather than

go too far, we could find more branches.

If you assume that the portalway is invaded, maybe we would cut off the portalway and perform

a side-to-side anemosis, but actually it's not invaded.

So, some of the reconstruction of the photo wave here may be avoided by a clear mobilization

and the separation.

I think that in less than three minutes, Professor Ha would remove the specimen successfully.

We used one hour and 45 minutes to remove the whole specimen.

Now we nearly came to the Heidelberg Triangle, and some lymph nodes are hiding here, and

some surgeons call this place as mesopancreas.

They think that the pancreas has a so-called mesentery, including nerve, lymph nodes, blood

vessels, and so on.

And now the part we put Professor Hao cut off is the mesopancreas.

By seeing the right side and the posterior of the SMA, the total, the whole mesopancreas

has been removed for good vision.

You see that when, because Professor Hao made a very good cattle brush, a whole maneuver,

so in this part, the only remnant part is the mesentery and the nerve plexus around

around the SMP and the C-lactone.

And what a great help from the harmonic scalpel.

now, in our center, we do not perform many ligations on this part.

In the past time, the only thing we do here is a

ligage cut-off, but now, when we use the layer-by-layer

method, methodology, we avoid making many ligations here.

we just legated the vessels we made. Okay, bravo, we have removed the specimen here.

Now we wash the whole operation field with natural sodium. Fortunately we don't need to reconstruct

the proper way as we did in this case. Great, great work really. Thank you, thank you.

Okay, great compliments and I mean it looks like it's it has been a smooth operation but

But let's give us the idea of the huge experience it's in those hands.

Yeah.

So actually, we plan to perform an artery-first approach for this patient

because we suspected the right wall of the portal vein is weighted.

But during the separation, you see only one centimeter's portal vein is suspected

as related to that tumor.

And by using the classic approach, we could look at good separation.

So our artery-forced approach is not necessary for this patient.

Now what we do here is Professor Hao is trying to remove the number 16 linfonode here.

Now here, I think if it's possible, we could make a discussion here.

In many centers, they regard the metastasis of the number 16 linfonode as a contraindication for radical resection.

But in our center, we found if there is metastasis in number 6-linfenol, like 6A1 or 6A2 or 6B1, that would not affect the overall survival of the patient, even if we perform a radical resection.

So I wonder, what's your opinion towards the metastasis of number 6-linfenol towards the survival of this patient?

Would you perform radical resection if you found metastasis in this region?

Well, you have the lymph nodes in your hands, so I really think you can perform it, so you can take it out.

But in Japan, actually, some centers, they perform the resection of the lymph node here first, at the very beginning of the operation.

If they found multiple lymph node metastasis here, they would regard it as YM1, that means distal metastasis.

So then a reticle resection is abandoned, it would be give up.

So I think this is really controversial, still controversial, for the number 16 linfonode,

whether that's a contraindication for the reticle resection.

But I think for this case, number 16 linfonode is positive, maybe, that does not seem like

a positive one.

I think it's a negative linfonode.

So for the dissection of the number 6 lymph node, we should be aware of the right renal artery that goes beneath the left renal vein.

You can see this patient has the right renal vein, and I bet that the right renal artery goes under it, just goes under it.

So the lymph nodes should not be lifted up too high to make the right renal artery go along with the lymph nodes.

And you may cut it down.

So just go along with the space of the renal way, that's enough.

You should not lift the lymph nodes too high.

And the ligation here is very necessary to avoid bleeding.

Also the lymphoid leak.

Okay, this is the 6B1 lymph node. We try to adjust the angle of our camera, but it's too deep.

For some easy cases, we would remove the lymph node along with the specimen altogether.

But for this case, I think that after we remove the specimen, we could perform an extended lymphodinaptomy after we remove.

That would be more safe.

Here, Professor Ha will try to review the root of the inferior mesenteric artery.

And only 6A2 and 6B1 lymph nodes are necessary for lymphodetectomy.

This is the soft tissue at the anterior wall of the vena cava and aorta.

That's the aorta we could see it. That's the left side of the genital fissure.

The homonidase would avoid more hemorrhage and also some of the lymphatic ducts would be cut off along with the little blood vessels.

But for some big lymphoid ducts, we think it should be ligated toward the lymphoid leakage after operation.

That would be really annoying to see nearly 1,000 lymphoid fluid from the drainage tube.

That would also affect the nutrition status of the patient.

Now we could see the lower part of the left renal vein, the lower wall of the left renal vein.

Here, just as I referred to you, this is the left renal vein.

You should be aware of the right renal artery here.

They go across with each other to the different direction.

This is B1, 6B1.

Yes, we have to conclude our lymphodinectomy right over there.

So Professor, I have a question. So would you, in your center, do you perform the lymphodinectomy of number 60 nymph node before the removal of the specimen or just after it?

I think it's better to have it right after, as you have done this way.

I think the exposure region is better, right?

a completely clear surgical field now and so it's easier for some surgery or

center they also perform this in the very beginning because there are two

steps there are two advantage first one is just give a good clinical staging for

this patient the other one is that we could find the root of SMA just the

infant of the right the left runaway by doing this they could touch the root of

of the SMA for a good evaluation.

So I think both of them are okay.

That's from a lymphodendectomy.

Remember to remove the lymph node in this area.

That's okay.

There are many little branches in the left genital fascia

here, goes into the lymph node,

so they should be cut off carefully.

we remove a total big lymph node,

but in our pathological report,

report, this kind of lymph nodes are also reported in 16 or nearly 20 lymph nodes here.

They will tell you that 0 in 20 lymph nodes are positive in number 16 lymph nodes, in

number 16 lymph area.

That's very interesting.

So here we have go to a very deep layer and we should be careful for some little branch

derived from the aorta.

left renal vein from the backside, I mean, to the anterior wall, and then you could perform

a block resection. I think both of these methods are okay. But for this patient, the number 60B1

So it's a little bit difficult for us to put it from the lower part to the upper part.

So maybe Professor Hao would separate it, separately dissect it.

Number 60B1 lipidome, check whether there are hemorrhage at the root of the lipidome.

We could see that Professor Hao tried to dissect the number 6A2 lymph node, the upper region of the left runaway.

The vessel Professor Gao tried to put to the other side is SMA, just now.

6A2 lymph nodes, the boundary of it is the left runaway and the celiac tract.

So if we go to the good space, number 16A2 lymph node, it goes along with the number

16 lymph node.

And from this angle, we could review the CDF trunc, and the lymph node could go along with

the neuroplexus part one around the CDF trunc, where it would cause some trouble or some

difficulty for us to review the root of the number 16A2 lymph node.

Here the exposure is a little bit difficult, maybe the camera would not give us a good angle.

Here we should be extremely careful to protect the right renal artery.

Is that the right renal artery here? I guess so.

I think this is the right renal artery that I referred to.

By hanging the left renal vein and the right renal artery up, we could find the right renal

vein.

You could see it.

The hanging of the certain vessels is very helpful in lymphodendroptomy.

Doing this, we could protect the vessels we need to hang up, and also we could make good

good space for lympho-denectomy to avoid accident, injury after certain reasons.

Okay finished.

Number 16, lymph node rescue in the lympho-denectomy.

Okay it's done.

So Professor Hao is trying to perform a lympho-denectomy in the Hedberg triangle, that is the soft

tissue and the actual chest along the superior mesenteric artery.

Maybe number 14 A lymph node is located in this area.

So by doing this, the SMA and the SMV could be separated completely.

I guess this is the nerve plexus along the SMA.

For some pancreatic cancer patients, when the tumor is located in the adenoprocess,

the patient would be very suffer from the severe pain.

and I think this is the reason for why they got pain, because the nerve

plexus is blocked, is compressed by the tumor. For the portal helen, I plan to

tend it for denectomy along the portal helen and try to find the

bifurcation of the right hepatic artery and the left hepatic artery. So this is the

posterior wall of the bell duct. So here we should keep the balance, we should

We found a balance for the blood supply of the bile duct also for P4-denatomy.

If we separate the bile duct, the remnant of the bile duct, too long,

the blood supply of the bile duct will be affected.

And that may cause the blood to leak after operation.

Here we find the right hepatic artery, I think.

This is the median hepatic artery.

The bifurcation of this patient is extremely low.

At the very beginning, I misrecognized it as the phenomenal hepatic artery, but now

we can see that it's median hepatic artery.

The first honing artery is the right hepatic artery, and the artery we are honing right

now is the median hepatic artery.

Now Professor Hao is trying to find the space between the phenomenal hepatic artery and

the portal vein.

sometimes we could find number 12p lymph nodes. That's the vessel derived from the portal vein.

That is the remnant of the right gastric vein derived from the portal vein. We could find a

very good space between the hepatic artery and the portal vein. When we do this, the number 12

lymph nodes could be dissected. So sometimes we cut off the right gastric artery and the vein

along with together but for this patient we could cut it off separately. This is a

right gastric vein, right gastric vein. Another ligation by Professor Gao. Another

hanging for the portal vein for number 12 lymph node total destruction. Actually

we found hemorrhage during this area and it's not a hemorrhage. What we should do here is try to

remove all the lymph nodes we can see and the hemorrhage could be stopped. Some of

this nerve around the hepatic artery. Actually here I remember a very good, interesting topic.

In 1960, a surgeon from America, I think it's a surgeon Michael, he classified the 10 types

of replaced hepatic artery autopsy and then it's too difficult for us to

remember the use that in 1994 Professor Head I remember name of his head it's a

liver transplantation surgeon and then he classified reclassified modified the

the derivation of the epithelial duct by six types.

We could find that number 8P lymph node along with the number 12A lymph node.

So Professor Hao is trying to remove the lymph nodes totally.

Here we do not like to use the harmonic A's here.

We could use harmonic C's.

We should make sure that the shaft of the artery is opened.

However, the outer membrane is not injured or it could cause bleeding dangers after operation.

Sometimes it may cause atrial aneurysm after operation.

So we should make sure that the outer membrane of the artery should not be injured.

But the chest could be opened.

That's maybe Professor Hao would remove this tumor from the right side of the pulmonary rather than the left side.

the next action to it from the left side to the right side right here because I

think the root of this pancreas is located at the posterior wall of the

portal vein so either side is okay but from this angle maybe the hepatic artery would cause some

lesson for anatomy of the portal helen and the mesentery around the pancreas

Number 12A and then 8P, yeah, number 12A, you can find the remnants of the left gastric

vein, it would be ligated, oh, it would be sutured.

This is the root of the left gastric artery, I think, that is sutured to reinforce the

remnants.

this, sometimes we should cut off the mid-colonial artery derived from the SM8.

and sometimes the static wave should be hung up to reveal that space.

Here we could have the SMV.

By doing this we could remove all the number 16 and 15 levels

along the SMA and the mid-collective wave.

Maybe we should open to your shaft.

That's the left side of the triangle.

Here we should be careful.

We could see the remnants of FDA.

And what we do here is try to open the 11 o'clock direction, the shaft of SMA here is

really thick.

We could open nearly three to four layers before we could really view the real outer

Maybe it's both into the splenic vein, I think.

sometimes I think I we could be cut for this case this is a splash away we

should mobilize enough of the posterior I made a mistake this is the last branch

and we drainage into that as a week here we could remove numbers 11 if no long

with the planning so I think that with this method professor how much more

lymph node as we can and then the pathologic TAM staging for the patient

would be that we just removed the specimen. The end staging of the patient would be

more accurate and then after operation when we choose chemotherapy arrangement for

this patient that would be more precise. Actually the strategy we use for the

chemotherapy after operation for this kind of patient depends on the lymph node

status and the tumor biology due to the depends on the pathological if the patient have positive

metastasis lymph node and the nerve invasion we will get the patient a papillotomy of the

genocytopenia or even the S1 plus genocytopenia chemotherapy but if the lymph node positive rate

is too high. I mean, it's much more than 20%. We would give this patient anorexia and gypsophilic

cancer. Sometimes modified fulvary nox is also necessary for the post-operation chemotherapy,

but the side effect of the modified fulvary nox is still too severe for post-operation patients.

aorta and the mini colon. So I think that's a very good picture for

studying of the anatomy structure. I'm ready to have to see the root of the

So, Professor Hao is showing the whole operation field after extended lympho-denectomy during

the PAM-22 denectomy.

We could see the splenic vein, portal vein, superior mesenteric vein, left rhino vein,

runic collar, common hepatic artery, right hepatic artery, median hepatic artery, as

well as the superior mesenteric artery.

So I think that vision is very good for extended lympho-delectomy after duodenectomy.

So this is the vision after removal of the specimen and the lympho-delectomy.

After that, we would perform a rebuilt reconstruction of the elementary tract.

Simply amazing.

Absolutely amazing.

We would wash the abdominal cavity with sodium, natural sodium.

By doing this, we could wash all the residue, blood, and blood tissue with the abdominal cavity.

Also, we could find whether there is little wound, little hemorrhage in our operation field.

So during this process, Professor Hao changed a lot of it to keep the tumor-free principle.

use absorptible thread for the continuous future.

So now the assistant is changing their gloves,

that's tumor-free principle.

The thread we use here is the 4-0 absorptible thread.

Future here is just to avoid bleeding.

Yes, it's just hemostatic.

You told us before you anticipated it,

you should have put these stitches on the ilium.

I myself don't know what kind of method Professor Wu Zhehan would use today for pan-fetal jejunal

stomy.

Maybe a modified block gut, maybe a continuous suture, let's see, let's wait and see.

That's the landmark for the part of jejunal we use for pan-fetal jejunal stomy.

So considering that the thickness of the pancreas, Professor Wu would use continuous suture.

for both the posterior and anterior side of the pancreas.

And then maybe we will perform a duct to the mucosa, and that's most of it.

So the quality of this pancreas is very hard and very second.

So I think that continuous suture is a good option.

And also, we would put a stent into the pancreatic duct,

and the other side of the stent would be put into the jejunum

make sure that all the pancreas juice would go along with the pancreas duct from the pancreas

to the jejunum and no restriction of the pancreas duct. So this is a continuous suture with four

zero parting stitch both of the jejunum and the pancreas with the suture as many tissue as we

you could to make the osmosis more safe and more space between the pancreas and the genitals.

The strategy here we use is 4-0-40.

In episode 4, the stitch is about 21 millimeters long, with a little hemorrhage at the surface

of the pancreas.

the node between the continuous.

the stitch we use here is a 5-0... 5-0 polydosagnon. Yeah, 5-0. So what kind of

thread do you use, professor? Absorbable thread or inabsorbable thread? I mean the

Pauling or PDS2 here? Probable PDS2. Okay. Yeah, I think that's a better choice here to use

because the restriction of the ductotomycosis after an anastomosis is a complication of pancreatodutynactomone.

So, Abisopo is maybe a good choice.

And here we would also make a fixed suture for the pancreatic duct, pancreatic stent, I mean,

to avoid the escape of it from the pancreatic duct too early.

And that would cause maybe grade B or grade A pancreatic juice leak.

We should double check whether that is the pancreatic duct.

Still, me, myself, I think that duct to mucosa and osmosis for the pancreatic genital storming is the best option.

The pancreatic duct is not dilated significantly.

Maybe we should resuit the anterior wall of the pancreas suture partially after we use scissor to cut it out.

We should find the pancreatic duct again.

The tube, I think this is a silica tube, it's very soft so it's difficult for us to put it in.

Length we want to put in is about 5 cm.

5 cm in pancreas depth and nearly 2-3 cm in jejunal.

This is a silica tube, 2-3 cm in jejunal, 5 cm in lateral principal.

Because if it's too long, sometimes we put a very long tube in pancreas depth and nearly 10 cm in jejunal.

We want it to cross, to go across the angiojejunal stomach to avoid the meeting of the two, I mean the banquet juice and the belgium.

But I think that's impossible for us to separate it.

So just the two centimeters, three centimeters into the jejunum, we do need to make it too long.

If it's too long, it will not be easy for it to escape from the pancreas after a long time during the recovery of this patient.

For the arterial wall, we do not use the 5-0, we use the 4-0 praline stitch.

And for soft pancreas, not such a sick one, we would also use the modified Blumgott pancreas

jejunosomy.

Pancreas jejunosomy, I mean, we would go through the pancreas, use the 3-0 praline, go through

through the pancreas, and then to the jejunum, and back through the pancreas.

We will perform three to four times of this throughout stitch to make the jejunum and

the pancreas very close to each other, and then from the duct to the mucosa, and that's

You can see that the angle of the stitch is not very good for the ducto-tumor stitch for this case, for a suture.

We made it...

I think that it's not so soft, it's very hard, and it's fractured.

I think the quality of this pancreas is very fragile, easy to be break during the suture.

Now Professor Howe is trying to make an anterior wall suture.

I didn't get if there is any absorbable stitch on the silicon tube.

No, I think that today Professor Howe did not perform any absorbable suture to fix the tube.

I think that maybe he thinks that the size of the pancreas duct is not big enough, and

maybe the duct could be fixed by itself when it is inserted into the pancreas duct.

We are able to use PDS plus Ditch for maybe a continuous suture for the glandular gestural

stoma.

But the belt act of the patient is not delayed significantly, so let's see whether it's going to be a continuous suture or interrupted.

I have a freezed image. I have to go to the technicians for a while.

That's okay, Professor.

It's freezed. I don't know. Okay, it looks like it's going again, but I'll go to them just to be sure. I'll be right back.

phalangio-glycemic stomy and I think that for some low-magnificency case, this kind of an

asbestos restriction of the phalangio-glycemic stomy and maybe some of the

phalangiolysis and after five to six years of operation, the patient came to the surgeon again

found stricter of the absorbent. We suggest to use absorbent thread. Also we can see that

the drift, the direction of the drift after should be very important, that close to

each other. The last supply of the anesmosis is also worth it. If you make too many more sutures in there,

if you use too many sutures here, that would cause the flaccid form, which may lead to the

Here, we make sure that the only osmosis formed here is the posterior wall and the distance

between the stitches is 10 millimeters.

That's like what we do head-to-head osmosis.

The techniques we use here at the principal, for some surgeons, some centers, they also

put a T-tube here for the out-of-block drainage.

I don't think that's the best way.

Only for those phalangioidic acid cases, when it's possible for them to take stones, but for this kind of only anastomosis, no stand or titio left.

After the phalangioidic adenostomy, the gastro adenostomy, here we would use another linear cutter to try to decide anastomosis.

and then we close the junction of the gastric and the jejunal, and the jejunal.

Here is the remnants of the back to the linear cartilaginous.

Professor Aminlouk?

Yes, here I am.

You don't use any experience using a vascular stain of birsungi jejunal anastomosis.

Have you any experience?

So you mean the calendula diagenostomiae or the pancreas diagenostomiae, professor?

I don't quite catch up with you. Your question is about the calendula diagenostomiae?

Pancreas diagenostomiae.

Okay, I see. Here we just, actually that depends on different surgeons here.

Here, me, myself, we use absorbable, like a PDS class for the pancreas, for the ductal to mucosa, anastomosis,

because I think that would make the escape of the stent from the pancreas into the jabs quickly enough.

We do need the stent fixed in the pancreas duct for too long.

But Professor Hao, they think that if you use absorbable prowling here,

that would make the fix of the pancreas duct long enough.

The longer the stand is fixed in the pancreas duct, the safer the patient would be.

Let's just reflect a different attitude towards the pancreas duct, the stand in the pancreas duct.

Me, myself, I use an absorptible thread.

So what's your attitude, Professor?

Would you use Pauling for ductal mucosa or absorptible PDS for that?

Here we put a nutrition tube into the fistula to make sure if the patient has DGE or the

grade A to B, we could give some EN for the patient, combined with TPN for nutrition support.

for the nearly 30 centimeters of the nutrition tube into the diagenome and the

gastric tube will leave. We will make five sutures here and then a linear

cutter to close the production of the gastric and the diagenome.

thing we need to do here is put a drainage tube into the abdominal cavity. Here we

would put three drainage tubes into that cavity two at the right side and one at the left side

the two tubes at the right side with the drainage for both the upper region and the lower region of

the pancreas and the left side we will put it into the little omentum just near the left caudate

long for the drainage of the villars okay it's almost done so dear professors here professor

how has finished all the operation for today's time to do the neck to me so shall we try to ask

this operation yeah this operation is a little difficult then i had i have affected yeah because

Because this patient has very severe inflammation, the tumor is located in the head and the neck

of the pancreas.

Also this tumor is a little enveiled, the GDA, so it's very difficult to make a dissection

of the GDA from the tumor, so it takes a little more time to dissection that column of the

liver.

Generally, this operation is successful, I think.

We have made a radical dissection of the lymph node dissection and to get the R0 resection

of the tumor.

But the tumor is a little big, yes, maybe three by four centimeters.

meter and because very serious information it make a big trouble for us to perform it yeah

we can show you the specimen of this patient we let's look at the specimen this is a specimen of

the patient can you see it this is stomach this is adrenal and this is head of pancreas we can

can find the tumor located here. We can. We have enough resection margin here. So I cut

the tumor. This is a tumor. This is a tumor. Can you see it? This is a tumor. The tumor

is 3 by 3 centimeters. It's very hot. This is the specimen. We also make a lymph node

dissection from the cross appearance that maybe have some lymph node metastasis. Maybe

Maybe some lymph node is infiltrated.

We were waiting for the pathology result

and to confirm the tumor stage.

In China, generally after operation,

we routinely recommend to the patient

to have the adjuvant chemotherapy

for the patient to control the currents

of the tumor or metastasis of tumor.

Generally, we give the patient

the six cycles of chemotherapy.

therapy. For example, AG and Fofranos regimen controls tumors. So I think this patient should

to give chemotherapy operation to prolong RFS and OSS. Okay, this is a very, I think it is

very successful operation because this operation is a little difficult. So I think we make a great

walk thank you everybody thank you so professor i simply don't have the right words to congratulate

for such an outstanding experience and the best compliments for wonderful skills it seems to me

that you turned a very complex procedure into a smooth one and i think it can be only performed

by a well-trained keep and in a high volume hospital my next question is i need to know

something about your hospital my first question is like this how many patients do you treat per year

because in 2008 we set up we established the first department mainly focused on cancer diagnosis and

treatment. This is the first department in China to just focus on pancreas cancer. In our hospital

every year we performed WIPO procedure more than 300 and distal pancreatectomy more than

400. So we have very big volume of patients. So in our department we just have

We have 12 doctors, so everybody is very busy every day because we have so many patients.

Besides the operation, we also make chemotherapy and immunotherapy for the patient, so our

department is a comprehensive center for cancer.

So also, we take a lot of clinical trial, so we try our best to give the patient the

more result because as you know the result is very poor compared with other disease so we

we devote ourselves to maybe to conquer it yeah yeah this is my dream maybe i think in the future

we can set up the collaboration and in some field for example new trial or for the operation

communication between us. We hope you can make more communication between us. Thank you everybody.

Do you have any other questions for Professor Tao?

I don't know if there are other questions from another channel because I really couldn't get what the

discussants were speaking about before but i i understood that you were speaking with them

so as far as i'm concerned the only thing is the best compliments for your skills and your

experience and i have to thank you so much on behalf of professor palacini yes thank you for

for staying with us during this wonderful congress ever growing every year every year we it's a

stronger and greater. So, thank you so much. It was really amazing to take a look at the way you

turned a tough procedure with such a lymphadenectomy into a smooth one. Best compliments.

Really great. Thank you very much, Professor. Thank you, Jose. Thank you for all your

suggestions and your careful observation of all the ways of our operation. And we are really

looking forward for the next time of the live show for operation or even from your center

and more cooperation between italia and china thank you thank you very much