F. CORCIONE

Okay, we start with the last intervention from Naples with Professor Corchone.

The next case is a really interesting case.

It's a female, 47 years old, ASA score 2, BMI 22.8.

She had already some intervention, just like an esplority and laparoscopic exploration for infertility.

cholecystectomy, cesarean cat, and reparation of umbilical hernia.

Well, the story of this patient starts two years ago when she referred to abdominal pain

at the Pegasium with the radiation on the backside. This pain was getting

always more frequent and more intense, so until last September she had to go

to emergency room to get checked. There they made a vascular CT and then

confirmed from MR scan, they found compression of coeliac arcs at the

level of the median ligament of the diaphragm, so it's known as Dunbar

syndrome or syndrome of the ligament arcuate of the diaphragm, so this is a

a really interesting case. I give the

word to Professor Corcione. Thank you.

The last

one, you are lucky

because this is

in my experience the third case

that I treated

for this

rare syndrome and

I think that thanks

to the scanner,

CT scanner, it's

easier

to identify this very

very rare pathology related to the stenosis of the Celiac trunk and so we are going now

to perform this operation and we put 4 trocars, 2 of 10 mm and 2 of 5, Garzina, and the trocar

of the assistant is to retract the liver is the same the same trochanter position of the

for the gastric surgery now you have the laparoscopic vision this is the most easy

and a traumatic and cheaper retract for the liver i would like to show the anatomy in this

the

The small people of the Bata G nerve, or the vagus, the Bata G is there, and now we go

to identify the franco or my friend francesco ruotolò

professor corcione

Can you hear me?

Yes, yes.

Francesco, here I am.

I heard all your anatomy in English and I understood everything.

English is terrible.

No, no, it's didactic.

So, how do we start, Francesco, this operation?

First of all, let's say that Ariola described it first and then Dunbar for the second, so as to give credit to the merits.

It is a non-frequent pathology, but for those who are used to working on the esophagus joint, such as you and others, it is an application of those knowledge as regards this cerebellum that comes to be compressed.

the cases are two or the ligament arcuate is too low for which it compresses the

arterial artery or this arterial artery is born from the time too high these two mechanisms

and a syndrome and therefore linked to ischemia that determines the compression of the type of the

cerebellum a nervous syndrome because there are the nervous structures the solar plexus

and therefore the symptomatology is of two types, intestinal ischemia and compression pain of these structures.

The intervention leads us, through the opening of the fractal part of the small mentum,

in respect of the structures that we can find, which can be the nerves, for example,

destinati al fegato i nervi del vago anteriore non il nervo di la targe che anch'esso del vago

anteriore e poi anche un'eventuale arteria aberrante di irtle che viene scansata ci portiamo

quindi sul pilastro destro del diaframma ci portiamo a sviluppare la finestra retroesofagea

cioè praticamente ad avere il controllo della dell'asse della aorta legamento al quadro è una

structure that unites the two pillars and determines what is the aortic eye that is a

little lower than that of the esophagus and posterior obviously and now let's see what you do

let's see the right pillar in the diaphragm and let's go to the right edge ready I feel you

well I'm following the orders no no no no we followed this morning all the interventions you

you have done on everyone's part and therefore we are dedicated to collecting this is for a while to try

to now completely change the field of action so that in the afternoon instead of falling asleep

we follow this but the options are two or we work from top to bottom once you have gone

on the vertical plane or from the bottom upwards which is perhaps better because it is more conducive to the

work of the surgeon who is working from bottom to top and frontal to the

celiac so if you approach it from the bottom up as as

recommended in a work that is written and practically maybe we see

how are the images but quite good only that a little load the colors

it is clear that this diagnosis is achieved through a beautiful analysis through

angiographic controls and then above all we will see during the intervention if there will then be an

eco-color double control let's see a little bit what is expected the thing that

in this caudato cava right pillar 1 2 3 thanks to you francesca compliments and

that is a program and this would highlight the tributary the right hepatic artery

the left gastric the beginning of the splenic after which he this ligamentous structure that

that may be thick, may compress the triplet, must be sectioned.

The section is a little slow because there is all the nervous tissue around that must be sectioned

because the structure must be released.

Here I am now bringing it towards the fibroblast tissue.

In the dissection of the triplet, like all these arteries, it is not only the lymphatic tissue that surrounds them,

but above all in areas like this, rich in nervous structures, there is a rather challenging dissection,

because they are structures that do not yield easily, there is a fibrosis, there is also the work of this arqueous ligament

that compresses and also creates a structural defense thickening.

on the other hand we have the phrenic and the first artery that we find under the diaphragm

lower phrenic then there is the tripod then there is the superior mesenteric at one centimeter two

centimeters but there are also many variants many but they have made a preliminary angiography

so we know for example that maybe there is not an artery that makes instead of the mesenteric truncocilio

The important thing is to focus the whole program on the cerebellum and then on the nervous structures that surround it.

I'm approaching the tripod.

Yes, and if we had to take the esophagus and make a crack around it to pull it upwards, that is also expected.

For example, in the work you did, you showed it, if necessary, however.

Why?

To have light on the retroesophageal window.

This is the left gastric vein that goes to the door and that is the one that is in front of the left gastric artery.

This plaque that Professor Corcione is lifting is a peritoneal plaque that has been historically called Usca gastropancreatic plaque,

Uske, which was a co-evo of the other one called Uska and which is practically

evidenced because this artery, this vein passes through it and therefore the peritoneum rises and it is a

fundamental landmark and this is the first point of approach. This artery is also made of

splint between the left splenic and the common hepatic on the right, favoring the surgeon

avoid that it can go into error because it is precisely installed in the center as spartiacque

certain there is also the station 7 7 those of the infirmary are there when they are sick they are sick

but here there is no problem of this type but they are always structures that are put in the middle of

These lymph nodes always give a bit of bleeding.

Let's take an 8-3-3-5 for Giada.

So, the pancreas is here.

So, if I want to find myself on the cerebral tripod, it is enough to do so.

But I can't then ...

Anyway, I can also prepare myself from here.

Meanwhile, let's also remove the common hepatic on the right, which is the other element of the tripod,

so that we already have two ready.

No, there's always something dirty in front of the eyes.

Something dirty in front of the eyes.

Let's wash it.

I tried to mobilize the tripod as much as possible on this side.

Now I'm going in towards the door.

It is clear that at a certain point, if one passes a line around the esophagus, it moves it away from the aorta.

Let's be honest, since historically the quadro goes from one platform to the other of the diaphragm and is interposed between the aorta and the esophagus,

if the esophagus is pushed to the left, in fact it makes us see better the whole plane of the aorta, the tributary and the components.

Francesco, now I reach the aorta now, is there?

Yes, yes.

Yes.

verso sinistra con una fettuccia ci fa vedere proprio tutto il piano dove si

deve lavorare. Però vorrei evitare di mobilizzare posteriormente l'esofago

altrimenti questi pazienti poi hanno reflux o quant'altro.

Ho capito perché in effetti su quell'altro caso che avete pubblicato un

You have a little bit of the esophagus worn out, but anyway, it depends.

If I can wear it out, I wear it out, do you understand?

Yes, yes.

You, another time, you started from the bottom up, that is, you first looked for the three elements of the triple C.

Yes, that there is one also from the top down, but you wrote that it is better to go from the bottom up.

Let's look for the common hepatic, which is a landmark, and then it takes us to all the others, at this point.

Follow my hands, bipolar, there are a lot of inflammatory nodules around the artery

You told me that

The problem is that the tripod emerges from the aorta, we have to free that

Yes, exactly

Not the one that is at the top of the gastric, do you understand?

I had to go down to find the origin of the tripod

Yes, exactly

I'm Gabriele, we hear you now

Here I have to open the space, where is the vein?

Because there is nerve tissue that surrounds those structures.

Nerve tissue, but above all lymphatic tissue?

Yes, but also the nervous is strong, because there are the ganglia, there is everything that is the solar plexus,

the so-called abdomen brain so it is a shirt that wraps these structures so much

for the analgesia that is done the infiltration of the breast of the ganglion for various reasons

they are really aimed at acting on that level let's say that the landmark of the common hepatic artery

would be the auspicious one what to see the common hepatic artery that the branch that brings us to the

I go on the artery, I never see it, I risk going, here's what I was saying, from the top to the bottom,

going to make this sort of myotomy on the periarterial fibrosis,

which is what we do when we go to the races, as we did this morning for the castrica,

as we will do tomorrow for the castrica.

Here you start to see something.

It did not indicate them, so basically the three elements are together.

certosino questo

Francesco? Yes? How many of these have you seen in your life?

No, I haven't seen any of these cases here, no. One with Sartori, this one you're doing.

This is the third one I'm doing.

It's not many years that this thing has been put into evidence, it's been 50 years.

Yes, someone described it a century ago, but let's say from an operational, surgical point of view, it has been talked about since 65, 70.

With the development of the arteriographs, angiographs.

Yes, because we are on the upper part of the pancreas, working.

Here we are starting to see something interesting.

A little more like this.

Here we are smiling.

Here we are smiling now.

Yes, it's true.

We reach the celiac trunk for the English surgeon.

What do you mean by surround it?

With a piece of wood.

So we see all the elements and you do the cleaning of the area of the tripod,

of all the structures that may be able to compress the tripod.

An exposure of the tripod, of the elements.

No, but what can you put on the fetus? I don't understand.

The hepatic artery, the left gastric, the splenic, and we have demonstrated everything,

and then when you do the double control, you can see that everything has jumped.

From here it is easy.

The double is not used neither before, nor during, nor after.

Well, but in fact ...

The ophthalmologist makes it intracorporeal.

Don't take it too seriously.

It's all clear.

There's a little spot in front of the eyes.

I've seen it, but it's a single-use.

It's a very interesting tool.

Costs are reduced.

I'm going to wash the eye for pleasure.

I'm going to wash the eye.

Do you remember Corcione, the one who was the founder of St. Thomas?

Who was the founder?

He was the founder of Lanza Regionale.

He came from...

from St. Francisburg.

Is that true?

St. Francisburg?

Yes.

What? I can't hear you.

No, no.

Mario Bagliamonte was telling me something, but nothing...

This is the toilet, here, dear.

I'm going to wash the toilet.

Raise the table a little, please.

Thank you.

Yes, go ahead.

Now we are free from the earth, now I have to try to understand what the passage is in this magnificent sea of structures.

Oh, oh, there is a bit of sun.

It's true.

Here it is, the hepatic here, I don't know if it's the hepatic, it's too small.

It seems as if you are liberating yourself from something that was suppressing you.

The structure is expanding as if it were liberating.

It's like you are breathing.

Yes, it's a bit like when you go for a few days and leave your wife.

That one breathes, that one breathes.

This is how hard this tissue is.

But in fact the nervous structures are the ones that give hardness.

Ok, here we are on the emergence of the tributary.

Here it is, if we wash it.

This is a patient surgery, you don't have to be in a hurry.

Are you in a hurry? No?

No, no.

Is the sign in a hurry?

No, he looks like an orchestra director, he's in the middle of all these channels.

I don't know how he does it.

Well, because he's dutiful, eclectic.

I don't know how he does it, but he does it.

Chapeau to the French.

Oh, now I'm a tripod, a tripod.

Not yet.

Yes, let's say the branches.

As if it were also a bit aneurysmatic, Francesco.

Look, in fact, you know, when there is an asthenosis, there is always a post-asthenotic dilatation of the vessel.

It is a rule of vascular pathologies.

That is, in the valley of an asthenosis there is the dilatation, for physical reasons, etc., etc., of the vessel.

You have not undergone them, but as if you had undergone them, because they are being evidenced.

Yes, I think that in surgery superficial things are harmful.

No, but no, I never understood, I mean that she is so liberated that they seem almost charged, that's what I wanted to say.

As a matter of fact, I had to do it because I think that…

Franco, I can say one thing, you and people like all those who have great experience,

but for example for those who do not have all this experience to take for granted that you go with these

tools absent to the vases almost that you knew one hundred percent what you have to do and that is

acquired but you who teach as many of you here within all the important professors and however you

forget how many difficulties you had at the beginning so in short for us common people

you have a bit of comprehension.

Comprehension, you said?

Yes, of course. I'm holding a vase.

It's didactic for those who need to learn.

And also...

You see now the artery, the aorta is here.

The tributum of the cortex,

because he told me it's a long trunk,

these vases are born ad modum tridentis,

it is said in Latin.

But if the left gastric is born by itself,

only if you say ad modum b b of type bipodal and here instead it is a tridentis and a callejón

callejón as it is and a callejón in signs and that other year it is a mess ok now I just have to see

the emergence of the triple from the time here it is that it has freed itself from the structure of the structure

that the arched ligament that compressed it because the cases are two or the triplet was born high and

went into the domain of the arched ligament or the arched one went down too much and it went to give

compression on the triplet those are the two hypotheses you are prepared no but because no this

stuff here on the hook which is a very beautiful book and that at the time I studied it was studied on the

Valdoni or Stropeni-Colombo, which was a wonderful book, and instead Gallone,

who was in the next generations, talked about these syndromes with beautiful iconographies.

It is a very beautiful book from the point of view of culture. He talked about this

Dambar syndrome, he did not talk about those who had discovered it before, but in short ...

It is clear that this little flow of blood through the vases of the tripe, especially in the post-prandial, where practically the flow of blood to the intestine is greater, created pain from ischemia, a claudicatio abdominis, something like that, so it was called.

called but then it is as if it were a treatment of a galassia he is essentially

releasing something that englobes that compresses that does not expand but you expand well and yes

because you intervened I see the garden well but this intervention is pre-recorded that we have

done the other time because this morning you are working I think everything is recorded

Yes, the colon, the rectus, the stem, the liver and the cord.

Anyway, the nervous tissue that surrounds these vessels is the basis of the famous K.O.

when one takes a punch at the epicastrium, because in fact that is called solar plexus,

there are semilunar ganglions on the left and right, there is a series of nervous structures

that practically dominate the functioning of the abdomen.

If they are suddenly succumbed, they can create a K.O.

So, the tripod originates here from the garden. You can see it very well.

Especially when you pull the structures forward, you can see that the tube is stretched.

Here it is useless to prepare it. Here it is free, as you can see. I don't know what to do anymore. What do you say?

In fact, you, let's say, this doppler intraoperative, you don't believe in this doppler color, do you?

These arteries are so prepared, what do I say? You give them a flush and boom, let's do the scene, let's do it.

No, in fact, but in the protocols of things you feel like, but then you make sure it's a superfluous thing.

But I mean, since they don't happen often, take a look, all in all, it doesn't make you drunk, right?

If I don't do it, I confess that Rotolo will call me and tell me that I did everything right.

But if we did the Doppler, we would be more happy.

No, but they are rare situations.

Doppler, you won me again.

They are rare situations.

In fact, it's a documentary.

Who knows?

Who can interpret it?

and at a distance of a couple of months an arteriography of control in short to see

the flow that is prescribed but yes but not immediately I do not want to exaggerate in

this preparation because on the outside we are not interested more than so much and that that ganga has been released

This one here on the side, you see the aorta is now free and the tripod is here, you see, the splenic, the hepatic and the gastric.

And maybe a little free under that division of the splenic and the hepatic, so we can also see that there is no tissue underneath that compresses.

You can see the left gastric here.

Where? Can you see it?

The hepatic and the splenic.

Yes, just below that you can see that there is no splenic.

Below them there is the mesenteric superiore that we are not interested in, but it is one centimeter below.

Because sometimes we also talk about celiac mesenteric syndrome.

So, hepatic, splenic, gas, one centimeter below that acute angle that is created between the splenic and the hepatic, it is dissected and you can see if the aorta is clean in front.

I'm trying now.

But in short.

Give me the Doppler, it will present the images that you will see live.

I can't.

We'll put a drain anyway, Ernesto.

Come on, ready for the Doppler?

Doppler, give me a bit of bipolar waiting here, a bipolar, it was interesting in this case to do it to Palazzini, I think it was not done, no?

Giorgio Palazzini, if you are there, hit a blow, if you feel me, hit a blow.

Doeringer did it.

I don't know, then he will tell me if he has ever seen interventions of the lady Dumbas.

So, force, Doppler, right because I am, we had a meeting until...

16.35

Come on

Guys, Doppler for Professor Ruotolo

Remember

For the carotids

I've never done it

I'm a

Receiving professor, though, seriously

I'm sorry

I have to do another intervention now

What are you doing?

No, what am I doing? I'm resting

Five interventions

But I didn't think it would end so soon. We're just waiting, we're wasting time.

I could have made another column today. Why didn't you make it for me?

Let's anticipate something tomorrow. Tomorrow is even more challenging than today.

But when you go around these vases with this tool and cut, how do you adjust so that you don't make holes?

How do you do it? Is it luck?

Give the images of the Doppler for pleasure.

The Doppler?

Color. So, do you see the images?

No, we trust what you say and then if you see it, it's better.

No, no, no. With the external you can take the screen back, come on.

But let's go with the external there, come on.

But if we don't see the external one, we don't care, we only see the internal one.

You see the internal one, don't you?

We don't see the DOP, the ecographic image.

We're seeing it.

That's what we're interested in right now, not the DOP.

Slowly, turn again, turn again.

Now we have it in front of us.

What's the noise?

We'll see.

Now it goes up on the pages.

because it is also important the mesenteric because let's say the pain

above all ischemia is linked to the mesenteric markedly the one that does not

make blood to the intestine that I have pain that has eaten that is another

aspect and what does the expert say that the flows are good

the expert who says there is an excellent three-phase signal well a spark

I translate what I'm saying in English.

So, let's remove the carcinoma.

We didn't mobilize it, despite the insistence...

Yes, but you moved it. The esophagus moved it to the left, abundantly.

I didn't put it on the toilet, I didn't...

The esophagus, you moved it.

... the lesion of the vagus, and many other things.

Here, it's impressive to see the preparation of the vases from the garden, I think.

I see, ok, the tripod, here it is, emerging from the garden, with the two vases, here they are, free to breathe.

Who is this guy?

If you don't have any other comments to make, Francesco.