TANG robot- assisted laparoscopic cholecystectomy + exploration of CBD

you can begin oh i can begin okay that's good that's good that's good okay uh good morning um

this is uh cn10 from hong kong and um where you get to participate this uh virtual congress um

italian digestive congress and i would like to show you our live surgery conducted in hong kong

And before I start doing the surgery, I would like to introduce the patient I'm going to operate on.

A female patient, 75 years old, who had past history of diabetes, hypertension, Parkinsonism,

received multiple abdominal surgery, including surgery for CA rectum, for recurrent CA rectum,

and also culture of transverse colostomy

and also on one location requiring the protomy for intestinal absorption

back in 2015.

He should be sent with acute cholangitis,

barysepsis, septic shock about one month ago

and be sent with cholangitis.

At that time, we arranged imaging study

showing a stone, a widow pig stone in the common dioduct causing dilatation.

We performed emergency LCP, confirmed presence of 2 cm common dioduct stone,

with a past extent inserted.

Next.

So, I hope you would allow me to do a live surgery

will both assist laparoscopic cholecystotomy

and exploration of common bile duct.

Is that clear for the patient history?

Repeat the question.

Is it clear?

I mean, regarding the history of the patient?

Yes, yes.

Perfect.

Let me just go to the back side

and introduce you to my operating team.

Okay.

Okay.

Look at here. I use the X-Line machine. I employ four robotic arms. One, two, three, four. And multiple scars in the abdomen. And also a recurrent incisional hernia. So we have to be careful when we first insert the choker.

I think largely I use the second arm for the camera and the first arm here and the

third arm as the working part and this is the last one the fourth arm as a

retraction part yes okay of course robotic surgery is not a surgery done by robot alone

I mean we have to get a team and doing the whole operation I got all these

I've got a very experienced scalpers helping me at the best side and they are helping me while I'm working in the console

I think that would be the layout

It's not actually

reverse

Transcendent position. It's not reverse transcendent position and

And talking from the dome and so and so

Any questions regarding the operating table layout and so and so?

Why? Any questions?

I want to do a question. Why do you choose the robotic way and not an open way? Because there are a lot of additions, I think.

Oh, yes, I see your point, but the previous operation are largely peri-embolic and also lower abdomen.

I mean, if you talk about the surgery today, what I'm going to perform is not just the upper part of the abdomen,

and there's no major incision in that area.

I think if we can perform it in minimal invasive way and patient could recover faster.

And if there will be multiple scar, upper, lower, and here and there,

I think I would think about doing open surgery.

But this is still optimal for robot surgery because the upper abdomen is free of any surgical scar.

Okay.

Okay.

Let me just...

Okay.

Let me just go back to the consul and think about, I will try to describe what I'm doing when I'm working at the consul.

If you've got questions, by all means, phone me the questions.

And I might be a bit slay in answering the questions, but this is still fine.

Okay.

Okay.

Let me just start the surgery.

I don't know whether you can see the consul well, the operative field well.

Now, this is the first arm, the hook is the third arm, and there's also the fourth arm.

So, even though this is surgery, largely for lower abdomen, but we still see a bit of adhesion in the upper abdomen.

Okay?

I put in gauzes, one here, the other one here, to protect the area, to avoid shorting of the abdominal cavity.

There's also a specimen bag, once after I finish everything, I put it inside, and then

get it out at the end of surgery.

I think this is the initial preparation.

Okay, let me just start doing the surgery.

Before starting the surgery, I think, get a look, I guess, this is the deltinum.

This is the deltinum, and this is the gallbladder, I guess.

and I need a bit of further dissection before I can say for sure whether what

structure I'm doing. Now I would try to see whether I can define a bit better. I

think this is rather common for reoperative surgery. I mean very often

there would be quite dense adhesion here and there. So define clearly about what

you are tackling with is pretty essential. On my left hand would be

I think we start to see this is the gallbladder, this is the duodenum, and this is the falciform here.

I think the landmark is pretty clear. Now I will dissect further.

See how the third arm is helping. We basically using the third arm as the rejection.

Can you see okay? Okay?

This is a nice by that

Inside about that, but I have to defy be better which is for better which is powder. I think I don't need two hours

What do you think? Yeah?

This is this is powder

Yes

So this area I would try to pack the girls around this area because whenever I cut open the powder

bit longer let me just adjust a bit the uh the image yes the image this is a bit better

i think this is the build up oh yes okay let's move on let's move on

okay i think this is the build up yes this is this area you are expecting to see the junction

function between gallbladder and the common bile duct. And this is the very contracted

gallbladder here. I think I'm not dealing with that gallbladder right now. I would think

about exploration of common bile duct, define a bit here, before I move on to excise the

gallbladder. Okay. Let me just show you the intra-operative

ultrasound apart from 55 and to demonstrate how it looks like on the ultrasound or something

so the anatomy is pretty clear now stomach pyruvate duodenum bowed up

and very contracted gallbladder now i'm waiting for the robotic ultrasound and show you

i think even without ultrasound you can tell quite well passing down there's a big stone here

But I would like to show you a wonderful image

How it looks like on Ultra Sound, okay?

有咩?

有咩啊?

入咗嚟先咯, Ultra Sound

有咩?

有咩話俾我聽?

Huh?

No, 咁都 no 得

有咩?

你轉咗去 Endoscopy, PNP

Okay?

Now, 出多時上

Okay, 係

大啲, 抹大啲

抹大啲

Modify

I think, 大啲, 大啲

Okay, I think you can see a big stone.

Can you see it on ultrasound?

A very big stone inside the common bile duct.

Do you agree?

I think this is the stone.

有冇connect嘅而家?

冇聲嘅。

Okay, I think next step.

走。

I will do the corticotomy here

to extract the stones.

帶出咪?

冇聲嘅點解?

佢哋冇咗嘅去遲。

我知,佢哋冇咗聲嘅。

Are you with me?

Are you connecting?

Any comment?

Any comment so far?

Is it disconnected?

I'll ask him.

Any comment?

Any questions?

Any questions?

I know.

I've asked him and he didn't respond.

But why didn't he respond?

I want to know.

Any questions?

He's watching me.

Is he watching me?

He's watching you, Dr. Tan.

Are you with me?

Okay, good, go.

I don't know how.

I don't know how.

Okay, do it.

Do it.

Don't care about it.

No, do it first.

Do it.

I'm scared.

Shut your eyes.

Thank you.

Now I'm going to excise the gallbladder

and then follow by repair of the colicotomy.

Now I'm going to excise the gallbladder.

I think this is a very chronically inflamed gallbladder.

係呀,因為佢WhatsApp e-file

Let me just, I'm so sorry and there's a bit of a noise issue

Let me just do a one-link comment here while I'm doing the operation

I have done the choroidocotomy, I have

retrieved the common bladder stone, I do the on-table

choroidocoscopy and confirm there's no residual stone inside, I also remove

move the bivouac stand inserted during the procedure of RCP. Now, I'm going to excise

bladder because this is the area you are expecting to see the common bladder, okay? I think this

is the area you have to pay extra portions. Even if you perfect the gallbladder, it doesn't

matter, but what seems to be extremely important, don't injure the common bladder, okay? It's

It's not a very friendly operator, now I'm going to excise it with a very careful way.

I hope you are still able to see what I'm doing.

He heard us.

Dr. Okay, good, good, that's good.

Okay, it seems that there's something here, but I'm not sure, but I will further dissect,

said. See when I

I may just cut it

and then fish out all the stone

and shoot straight back

just in case. Clean up the

hook.

That's good. You are still able to

listen to my voice.

Now, I

almost finished the surgery. I

have done the

ECPD exposure command

now I'm moving to

something here in the

duct because i want to pee everything it looks like there's a leveling in this area but there's

also another pouch in the systemic area and now i can see when i move down a bit able to see a

hole this is probably connected to the cystic duct so this is the area i would expect

to see the connection of the Gorbet and also Kampenbauder, and this is the Sitsikdak area.

I guess this is Tartman Pouch. There's a bit of outgrass appearance slightly higher,

so this is still Kampenbauder. Okay, I think this is the situation.

I plan to transit here and then decide what's here. Okay, I might transit a little bit further

in case I can see stones in the stomach.

Because there's no cure anatomy in this area.

I think it is still safe right now.

Whatever receptor quickly transferred to the back,

I will prolong contamination with the abdominal cavity.

And then I would do a bit of hemostasis.

I see something.

I see a pouch.

I see a pouch here.

there's still inside can you see it i might have to reset a bit more this is probably still the

cystic duct stump look at here this is the pouch still connected okay so my next step would be

to see whether there's anything i think this is still the cystic duct area okay

Okay, let me continue.

The only worry, what I've got, this is not the six-stick duck's thumb.

That could be the white possible yin-chai-pi-de-dum.

But I think upon opening here, I'm pretty sure,

now I'm dealing with the six-stick duck's thumb instead of the white duck opening.

It's not too easy because another thing we cannot be seen very well.

very well. I would try to transet here, okay, and then structure closure of everything around

Okay, there's a little driver. I hope the voice can come back soon, but I'm still describing

what I'm doing. Hope you can hear well with monocle, SAML. Okay, good. Okay, this is the

monofilament, ideal for robotic surgery. Very minimal friction when you

of surgeon instead of closing it with primary caution they would prefer to put

in something like T-tube but I guess the evidence right now is good enough to

support there's no routine T-tube because T-tube simply give you a lot of drawbacks

in terms of complication in terms of delay the recovery time and so and so

particularly for minimally invasive surgery.

not very huge one, I mean about

1cm, 1.2cm, I rather prefer to

close it in an interrupted manner, because

continuous closure is associated with higher structure weight.

That's why my personal

experience

and suggest

it would be a bit safer and think about

inter-optic closure.

But if you talk about a very huge

sheet I did come and buy it up,

say for example, 2cm

in size and so and so,

you probably don't need

inter-optic closure.

Clean up the lens.

I hope the surgery is not too

boring because it's a bit simple.

Initially, I plan to do a different reception, but the case is not available, so I chose

another one.

I hope this is still good enough for the purpose of light demonstrations.

Look at this.

This is how we are doing.

You can use it as a needle holder.

You can also use it as a scissor, because there's a life at the proximal end of the

the instruments. This is needle cutter. I think this is a very good instrument. I still

have 5-10 minutes to go and I hope we can reconnect it once again with the sound and

I intend to leave it here because, let's see, I want to save a bit of money, bear with me, I want to save a bit of money.

Okay, okay, okay.

Thank you.

I'm so sorry.

I think the voice issue cannot be settled

by the time I finish the operation.

I think I will just carry on

and telling you what I'm going to do.

I think I will just continuously closing it.

And this is the last closure.

This is the last closure.

for one or two days.

If there's no power leak,

and then I would remove it.

I would also monitor the

liver function possibly

to see whether there's any

abnormality. Even though I

checked everything with the

colitoscopy and there's no residual stone inside

but you have to

prove beyond doubt. Let's see whether

I got anything here.

Let me give you

a new gospel.

Give me a new gospel.

I want to check once again

the culture, whether this is

Is it intact or not intact?

I want it.

Let me put it in the bag first.

Put it all in the bag first.

Put it all in the bag first.

I don't want it to be so dirty.

Okay, I put everything inside.

And then I close the bag.

Give me a little water.

It's better.

Let me see.

Okay, I put it at the subthinic area.

Okay.

And then suck here.

Give me a little water.

Give me a little water here.

Okay.

Give me a little water here.

I would like to add one more here, okay?

冲啊冲呢度。

冲啊冲呢度。

It's too bright.

比多针我。

I think the cold shirt here is okay.

The cold shirt here is okay.

I think I would add one more here.

依楼的。

I'm sorry, I finished the search a bit earlier than my original schedule.

I want to show you in two hours, but now it's just not even an hour.

Whether the kosher is secure a lot. I think it is okay. What do you think? I think it is okay

last

last stitch. I will leave a drink

in that area

I will leave a dream

in that area

and leave it for one or two days

before I

pull it out because

there is still a remote chance

even though at the moment there is nothing

you might have a bit of issue

I hope you are satisfied with the

culture, the surgery

it's not particularly easy

but also not

very difficult

I think this is the way how

we demonstrate the use of the robot

to do the operation

because anatomy is clearly

identified

if not because of robot you might have a bit of

concern on how to dissect

and also

with a bit of difficulty when you try

to close the chiropractic

dichotomy.

唔好轉,唔好,唔好,整咗咁多先。

等下先。

I would never drink.

Oh, finally, I hear a voice.

Finally, I hear a voice.

What happened?

Finally, I hear something from Italy.

講脫,講兩下又脫咗啦。

出咗未呀?

OK, I think that's it.

That's it.

OK.

捉咗條 shing先啦。

講兩下唔好做。

I know I can't hear anything from you, but this is how we perform the robot assist, the

prosopic cholecystectomy, and also exploration of the commandos.

I think the tricks of the whole surgery, you need a very careful PRP depending.

You know what pathology you are dealing with.

Even though in the presence of multiple abdominal surgery,

and you evaluate what will be difficulty you can encounter when you are doing the operation,

and you insert the first choker safely with the use of optical choker.

Second would be a team approach. The console surgeon has to work with the

backside surgeon and do surgery together. Third, I think the enhanced visualization

in terms of use of ICG, 3D vision and also the intra-pediatric ultrasound

arm do help me a lot to divide clearly the anatomy last but not least would be uh the uh

dexterity confirmed by the robotic arm and in fact can i i enable you to do the uh posture of

the cystic ducts thumb as well as they call it caught me quite well and uh i think that's the

end of the live demo i'm so sorry i i can't hear anything from you i hope you are fine with the

surgery. I didn't use up the whole two hours. I just finished the surgery in one hour. I hope

you don't mind with it. Hope I can have chance to be involved in any one of your workshops in the

future. And thank you. Thank you once again. And all the best from Hong Kong. And this is Sienten.

Okay, I think that's the end of the live transmission. Bye-bye.