Laparoscopic-Assisted Right Hemicolectomy

CHAPTER 1

So just kinda stop at the corner and rotate. 15 blade is fine. With this curve. Yeah, incision. Incision. 8:28 incision. Good hands. Knife down. Adsons, please. You can go a little wider if you like 'cause it'll cut. Just grab here. Keep going straight down towards the belly button kind of. You can open a little bit more. Little bit more. Remember, we're gonna need all of this incision. At some point. Yeah, yeah. Go ahead and grab it here. And then work not this way, but towards the belly button. All right, we'll take a Kocher, please. So keep on holding here. So we're gonna work in towards the belly button and bluntly. And then you see the base. Now, we're gonna do two S-shaped retractors, please. It's kind of blunt dissection here. Okay, another one to Dr. Williams. Let's clean the the fascia. And if we can give the patient a little bit more paralytics, that would be great. Good. Now lift it up for yourself. Okay. Okay, can I have a 15 blade knife, please. All right, yeah. Thank you. I appreciate it. Okay, we'll take a - knife down, we'll take a tonsil, please. Did she have a previous surgery or no? No. It's fine. So you can feel this - you can feel the posterior sheath a little bit deeper. So you see how if the tonsil doesn't dive in right away... Yeah. I don't wanna poke it. Right. So what we're gonna do is we're gonna just make, go ahead. I'm just gonna make a formal cut down. Okay. So go ahead, and a little bit more Bovie. So if you are... Meet the resistance. Posterior sheath, yeah. Yeah. There's no point to. We still need to make an incision. So let's go a little bit longer Incision cephalad. Good. That's good. Good. Now we'll take another Kocher, please. So now Jelani, we're gonna just grab this side just like we would usually do. Okay. Another Kocher, please. I think I missed it. Okay. Got my side. We just go ahead and get your side. And you're sharp on that? No, just continue. I think we're in. Yeah. Syringe. So, and that's sort of one of the reasons we need to make an incision at the end of the case. We don't have to worry about making it too small. And we can actually start with the ten since we already have a 12. The gas on. So Derrius, go ahead and press on the flow. You see it says three, make it as high as 40, please. Thank you. That's the four men's test. Sometimes this is on a Verress needle, and you'll be struggling the entire case because you can't keep insufflation up. So now we're gonna first take a look inside, make sure there was no injury. Okay, look at the liver, make sure everything is okay there as far as we can tell. Okay, yep. Looks pretty good. Pretty good. So now, the port placement. Yeah. So the way that I think, and I'm gonna use just a ruler to show you, I'll take a ruler. So the rationale is this, that you need to place ports where it's ergonomically comfortable for your hands. So typically it's just an eight centimeters. If you put them too far out, then your instruments are gonna have to go too far in. Yeah. And you're gonna have fulcrum effect where a lot of instrument is in and a little bit of out. So your small movements of the hands will translate into wide movements. Yeah. Here the opposite could be the case when you have to work close to the midline, then you have to work straight in. But I think since most of our work is gonna be done... Yeah. Towards the right. And you have a marking pen. So you do the eight. Roughly eight. Just, you know, you - once - so some people use the fist. Yeah, I've seen that. So, but I'll show. So you can just say about eight here. About eight here. So it's equilateral triangle, something like this, okay? So it doesn't have to be perfect, but just kind of, so it looks... Yeah. Like it's a triangle. And even in patients who may be on the heavier side, especially on the heavier side, when you feel like you wanna put lateral, then you definitely don't reach hepatic flexure, okay? And you do local at the end or during? On these big cases, I don't do local, okay? So, and Bovie is actually fine because cosmetically it all looks the same. Okay, so - think about the movement of port. You just have to twist it and be patient. Let it work through the tissue. Then once it's through, aim it in. Do you prefer these to the regular five? Mm-hm. Because these ports by definition don't slip. So when you have a long case, that may not be going very well. It takes a long time. And you put - push the port in, and pull the port out, push the port in. Yeah. They eventually lose their grip, and they start slipping with the instruments. Very frustrating. Another thing, when you have a heavy patient, really heavy patient, that actually makes a huge difference. 'Cause otherwise the ports will, the tips will hide into the, the ports will hide into the, fat back again, and the tips will be lost. They'll also slip out. So this is my preferred. Okay, so Jelani, you're gonna put one exactly opposite. That's gonna be our assist port. And we are gonna undo this spaghetti. Just one second, okay? Same thing. Not too far, not too close. Just right. It's small. I think it'll go, yeah, too small. These are balloon-tip ports. At least 8, 7, 8 millimeters, ah-huh. Let's go, ah-huh, medially. That's it. Remember it's all about if you make incision long enough, it heals as a line. Otherwise, it winds up being a circle. Patience. No, no, patience. Now aim towards, yep. And just slowly twist. Good, perfect. So let's move this to the assist port. And go ahead and open it up. Good. Okay. Can you show me the port here? My balloon is off and... Here we go. Okay. Okay, we'll take a table down, please. So step number one, go underneath everything so you don't bump into - go underneath that. Good. That's pretty good. The Trendelenburg is pretty good. Can we have a little right side up, left side down. We'll take the, whatever light you need, just let us know. But otherwise we would like to take the light down. So go ahead and slowly. One step at a time.

CHAPTER 2

Step number one is omentum needs to be over the liver. So take your time. Preferably don't grab omentum, and get underneath it, and flip it like a pancake. Correct. Use both hands. So see it's stuck to the cecum. Show me. So it's stuck to the cecum a little bit. So lift it up and see if it's a lot or a little, okay? So you could see a little bit of inflammation - is it appendix or...? Just go ahead and take this off the cecum because it's gonna help us to work. Small movements. Remember this is not the MIS, this is colorectal. I think it's low, okay? You don't have to be greedy 'cause it's coming out. So just a little tension coming to the hilt. Okay. Oh, yeah. More kind of, yeah. And press the button and squeeze. Squeeze a little faster. That's it. Good. Next. Good, continue. Okay. A little side to side make sure you got good. And then go into the hilt. There you go zip. And you squeeze fast? You like to squeeze it faster. Yeah, you can squeeze faster depending on what you are dividing. You know that there's no major blood vessels here. Right. So there's no need for you to cook it, you know? So just go ahead, stay close to the colon a little bit. That's good. Close? Yep. You know why? 'Cause, that's where mentum is attached. Right. Okay. So we grab with tension on it. Just a little bit. Just so that you can present yourself. Yeah. You see what I'm saying? You don't have to pull it apart. Good. Good. Okay. Good. Continue. We grab a little closer. Your right hand. Good. Very nice. Lift up. Good. Continue. You wanna put our balm stuff or get that later? What's that? Let's see if it's attached. Just let go for a second. It's not attached. You just grabbed two. This is... Continue. Okay, good. So split 'em a little bit. Split 'em both. Wanna split the two in the...? Yeah. Yeah. That's fine. Good. Very nice. And take the posterior a little bit. Nice and smooth. Good. Very nice. Okay, let's see if it's gonna be enough. Her cecum is a little bit high. So switch to graspers and see if you can get the omentum over the liver. The reason we need to have omentum over the liver is because we want to expose the root of the mesentery, and also, something attached, that's fine. We can ignore it if we don't have to. Okay, good. Good. Okay. All right, now, let me show you the next step, Jelani. So switch for a second.

CHAPTER 3

So now if we were to do a medial-to-lateral, what we wanted to do is we wanted to expose the root of the mesentery. So you see how the small bowel root kind of, you can, some of it you place into the pelvis. That's why you don't want to have too steep of a Trendelenburg, so the bowel doesn't flop back, and sometimes the bowel needs to be placed into the left upper quadrant. Yeah. So putting this over, the good question next is, can we visualize the duodenum? Because with the medial-to-lateral, what I prefer is to see if we can identify the duodenum. So this is, you can kind of see... Why don't you grab an Enseal? Enseal. Work from the assist port. And you prefer medium-to-lateral approach. Yeah, medial-to-lateral. Because you started with identifying the duodenum and then you stay out of it, okay? You'll see, hopefully it'll be, huh? Just go ahead and split it. Just take your time. This is thick, so you'll have to cook it a little bit better. Okay, go ahead. Full round. Just make sure you get the boom. Good. Next one. Posterior aspect. Patience. Okay, so it's pretty good. So now Jelani look. So this is... So we need to confirm the anatomy. If this, what we think is an ileocolic pedicle. Right. Sure. Duodenum is right here. And I wanna make sure that this vessel runs directly into the cecum. So just follow me a little bit. Okay, so confirming this is cecum. This is the TI. Appendix is here. Gonna retrocecal. Yeah, A little bit. So all of this matches. So you confirm the anatomy. That's the key, okay? Now what do you want to do? Is you wanted to put the ileocolic pedicle under tension. So you see this tension tenses up. So now you can take a grasper. Another grasper. Or if you have it, that's fine. And see if you can maintain this tension. Show it to yourself, grab it next to me, and then I'll release. Show yourself. So you don't have to grab the cecum properly. You can grab a little bit more of a descending colon here. Open up widely. Okay, and take your time, get this ileocolic pedicle under tention, okay? Okay, so it's the way that I think is anterior, lateral, and caudal. So anterior a little bit more tension. But now I'm gonna get you started and then we're gonna switch, okay? So the way we do it, and this is kind of a tricky part of the operation, is you put the camera down so we can look inside actually, probably not necessary. So let's look it this way. I'll take the Enseal, please. And you wanna make sure that you can enter in a clear plane, okay? So the way that we do it, again, we are gonna confirm the location, duodenum. Duodenum right there. The pedicle. So the way I do it is just you just score the peritoneum. You don't have to do much more. Just one quick bite. So rotate the camera a little bit, just the entire unit. So it's parallel to the ground. This one just rotate. Yes. Okay, now keep it like this. So notice here, patient is the virtue. So you get your instrument in, you lift up, you bring in, you come in five times - 1, 2, 3, 4, 5. You say, "Oh, nothing happens." It's okay, nothing needs to happen, okay? Okay. And then I'm gonna switch with you and you're gonna do the same thing. So I'm gonna reposition you now, one second, Jelani. Okay, come in. So I'm gonna show you where to go. You see how to clean? Yep. So notice this edge of the more caudal edge. Use this side of the Enseal to do like a C-like motions. Keep it closed and then just rub on it five times, one, push more aggressively, caudally, and less down. More caudally and less down. Just on the edge. And then do the same thing for the esophageal edge. Just open it up, just gently. Just rub it. Just rub it with a ribbed portion of the insil, not with the smooth. All right. Just curved motions. No, one second, Jelani. Ensure what I mean. The motion should be, kind of a curved, C-motion, yeah. And then make sure you rub on the very edge. Not inside, but on the edge. You opening up the opening. So rub right here. And take your time. 10 times - one, just more like a C. 2, 3, 4. Good. So now I'm gonna come in and help you, okay? Now we grab more caudally with your instrument and go deeper. Deeper caudally? Mm-hm. So I think that you might need to be a little bit deeper and just push everything down. Deeper and down. Notice how some of this is running parallel. Yeah. That's the retroperitoneal stuff. Okay, so, yeah. Push everything down. Just 10... So push now the whole entire tissue down, The whole thing down. Gentle. Like little taps. Go to where my instrument is. Oh, right here. Push down. Yep. One. That's it. Tap. Okay. A little tap next time. A little tap next. Different spot every time. So keep your instrument closed. The reason you wanna tap different time, different spot is because if you tap the same spot, you can actually work an opening. A hole, yeah. Correct. Do you see the vessel right here, Jelani? That is the vessel that belongs to the mesentry. So it kind of gives you a little roadmap. Everything else goes down, okay? Different spot. Different spot, and just keep doing it. Tap, tap. Almost like you have a rhythm to it, tap, tap, tap. Different spot and go caudally. Tap, tap, tap. No, no, don't go higher. Go caudally. Caudally is the safest way to go. Correct. So now we're gonna get under the cecum. And notice how firmly I'm lifting. So go ahead, tap, tap, tap. Different spot and just rhythm. Tap, tap, tap, tap, tap, tap. Don't admire your work after you finish. Tap, keep your instrument closed. Tap, tap, tap, tap, tap, tap. Like you're tap dancing, okay? Different spot, perfect. Different spot. Now your instrument could be a little bit more posterior. Your grasper, ah-huh, your retractor. Position more posterior. So not cephalad, but more posterior. Means you see where the plane is right here. So you get your instrument and grab that plane. Even lower. Even lower. Even lower? Yeah, yeah, yeah. Good. Now, go ahead and lift up. Tap, tap, tap, tap. Different spot. Different spot every time. Tap, tap, tap. So we're gonna get under the cecum, okay? Right next to that. Okay, good. So medial-to-lateral is better because we're working away from the duodenum, Right. Unlike the lateral to medial where you're working towards the duodenum. So notice how frequently I'm re-grabbing so I'd like you to kind of be also as dynamic with your re-grabbing. Okay. See your left hand is not in motion. Good. Now let's stop for a second. So I'm gonna go here. Okay. One second, Jelani, we're gonna work a little bit more cephalad, okay? So the same thing, okay? So left hand, left hand can help you. Actually right. Yeah. So keep it where it is. So notice, first of all, rub this thing to give you a little bit more room. Get one to keep the instrument closed and just rub, and then push down that stuff gently. One different tap, different tap. The area. Good. Good hands. Different tap. Good, let me push a little bit closer. But very nice, very nice. See it seems like we're not making progress, but we made a lot of progress. So the duodenum... So let me switch with you, I'll show you how to work the duodenum, okay? Jelani, you switch. So the duodenum does not have a good serosal coverage. Right. So you wanna make sure that you approach, instead of rubbing it like we were doing the other one. So here's how you approach the duodenum. You come in a little bit. And I would like to let it just drop. So what I do is I come in and I grab a little bit of this lining, and I just zip it, okay? Okay. And then, so this here, you have to be careful, see this vein of Henle. So you don't wanna divide this because that bleeds and gets your operation in the place where you don't wanna be, okay? So notice, no rubbing on the duodenum. Just get into that plane quick quick. Yeah, yeah. And then almost no heat, okay? So, and then just very almost like with your fingertips, tap, watch for the vein of Henle. Don't divide it unless you have to, okay? And the reason you do this from inside, it can help you from the outside. So let's go back. And I'll show you what I mean by inside-outside is. So we're gonna tidy things up a little bit. Okay, so now let's take a look here, Jelani. So I'm gonna grab this one, this vascular pedicle. You see the duodenum? Mm-hm. So now we can divide it. The pedicle? Yeah. So we see where we are. So we just divide it. And the Enseal is good enough for that? For this one, yes. Yeah. Yeah. Just be patient. Makes me a little nervous though. Me too. But you just cook it. You say a prayer and hopefully it works. So now you see the vascular pedicle pumping? Yeah. So now we have done the medial-to-lateral dissection. We saw the duodenum. We saw the duodenum here. We see it's down on the bottom, so it's safe. This is all we really need to do. Now let's go to the bottom, okay? So the way we do, just give all the instruments back. So I'm gonna get started and then you're gonna continue, okay? All right, Jelani, switch with me. You go towards the top. So now we just need to unzip the TI. So let's look at the TI. Well, here my preference is to take all of the bowel. Can I have another grasper? Up and out of the pelvis because it'll help to put the proper traction on the TI, okay? So it's all the way flat. Yeah. Yeah. So now what you wanna do, Jelani, is you just kind of unzip it, okay? Zip that sign right there. And it's the same thing, right? Quick heat, quick. Peritoneum. No vessels. Zip. If you feel like there's a vessel you can cook. And a lot of it, remember how we talked, we did this at the colostomy. Yeah. A lot of it is medialization because you wanted to join the previous plane of dissection. Make sense? Yep. And be patient. The plane will come to you. So underneath? So underneath. Ah-huh. The plane will come to you. Just be patient. So retract everything medially. And so essentially think of retracting it towards the spleen, okay? Can I have a grasper, please? That's it. You can start by just letting the CO2 in. Just kind of zip like one, a little bit bigger. Zip. Ah-huh, good. A little bit more, a little bit more aggressive. Zip. Good. Now retract. That's it. Now close your instrument for a second, and do 10 sweeps the other way. No, no medial. Medial. And pull as you do in it. Continue pulling aggressively. Remember we're removing this part, so... Okay, go ahead zip close to the bowel. Same thing. Lower down a little bit your grasper. Good. Push. Push in and medial zip, side to side. All the way to the hilt. Zip. Good. And we'll regrasp occasionally. Yeah, a little bit less Trendelenburg, plase. See, there's no plane. Yeah. So don't rush. We'll regrasp and build tension to ourselves. Yep. Remember, first, close your - grasp, we'll take a little bit less Trendelenburg, but a little bit head up. So we can take, sorry, I don't know your name. I'm sorry. Can we do me a favor and put the patient's head up, and slightly reverse Trendelenburg? You got it. Mm-hm, thank you. You're welcome. Go ahead. So Jelani, open your instrument and then engage the leaflet, and go side to side a bunch of times. Good. And then just go zip. Now the right hand has to pull towards you. That's good. Thank you, it's perfect. Good. Very nice. Ah-huh, good. Now grab where you're working. Now here, some of the tricks, Jelani, is that you wind up always going farther than you need as far as the hepatic flexure goes. So at this point we're gonna stop. So just go ahead a little bit more. Okay. Zip. All right, let's see. We're gonna continue working it, okay? More proximally? Yeah. Yeah. Get a little closer to our marking. Mm-hm. I think we might be a little bit too lateral. So let me switch with you. I wanna see if I can find the plane. Here's what I like to do. Her cecum was a little high. So, which is okay, we see this a lot. It's not like malrotation, but, so we're gonna move this bowel out of the way. You see this plane? This is takes a little, you will use the same thing when you're trying to do complex appendectomy. Yeah. You see this plane right there? So this is where ureter lives. And so what I like to do here is, Jelani, I use this kind of almost like a reverse motion. So, and this is... Another thing, you would be surprised how close this could be to the duodenum. Right. So what I do, and you'll be doing it on this case, it's kind of, we flip it back on itself. And then this allows me to get into the plane. You see how close this ureter? Right. Right. So you have to be cognizant of it. But this is unfortunately where you need to be for the dissection to join the previous plane. Another thing is to get the ileum to reach to the colon- Yeah. You gotta be a little bit more. So you see our plane is here, but what really needs to be is here. Huh? Keeping lateral now. Yeah, no, no. This is normal. Okay. This is how we unzip it. I told you to go there. Yeah. After you unzip it, you start going a little bit more medial, okay? Okay. Can we have a little bit more right side up, left side down, please? So this is the ovarians, ureter is here. Good. But you're right, you don't necessarily have to identify the ureter, but it's good to. If you see it, you just notice where it's. Yeah. So, and again, you see, Jelani, this is the common thing. If you don't wanna... Be that lateral. Roll it out. Yeah. So stay close to the colon. And ultimately what you wanted to do is you wanted to see if we have a little bit of oozing in there. You can see a little dark staining from blood. Yeah. But if you don't see - we didn't have oozing, fortunately. You'll just have to be precise in your plane. So in kind of a weird way, when you have a little oozing, it kind of helps you. But otherwise we're just gonna be guessing, you know, looking for it. And notice again, relative how far we from this and how far up we are. Yeah. And this is where we're joining a previous plane. This is appendix. You can see kind of a little full. Okay, so I'm gonna hold this. Just let you have a feel for it, okay? So, and I'm gonna try to see if I can help you. If it's not in the way, that's it, Jelani. Unzip it. Continue. You don't need to dissect. Just kind of get in and unzip. Work your retracting hand a little bit. It's down and out. Yeah. Okay, be cognizant of this colon. Good, now let's see if we can release a little bit more here Of the stuff more laterally? Yeah. So let me work back again. Hold this up. So... The reason the bowel isn't in our face is because the TI is attached to all of this. And it's always gonna be kind of flopping around. So now we have, look here. So we have this plane. You see this is the stuff that we already released, okay? This is our medial-to-lateral dissection. And we're just joining the two. Yeah. If we would've had like a student do some across it, but that's fine. It's fine. Notice, Jelani, right here. You see this planes here? A little bit. Yeah, yeah. So you just need to work these planes as well. So with the oozing, you said you think that that lets you know you're in the wrong plane. Say it again? With the oozing, you said... Oozing, it tells you that you're in the right plane. Right. But if your medial-to-lateral was clean, without any oozing, then for you to identify the plane, you just have to travel in the right plane. That's it. You see what I'm saying? Meaning that you have like when, let's say you work in the retroperitoneum, and suddenly, you see a little dark staining. Yeah. And you'd be like, "Oh, yeah, that's my spot." Okay. So here is another thing. You see it right here. And that's the technique that you continue to use. So now I spotted it. So now I'm gonna grab it. Left it - remember the duodenum is your frenemy. It's gonna be right there. The tissue's a little bit more mobile, which is great. Show me here. Okay, so we almost done with the, let me get a grasper, please. Yeah, I realized that holding this assistant port... Yeah. Is gonna be almost like getting in our way, so... Okay. This needs to be released for sure. Yeah. Yeah. Because otherwise, we can't reach the TI properly. Let's see if I can get you to hold this one Jelani. Yeah, we'll see if the movement of the hand is gonna be acceptable. One second. I think we might be okay. And part of it is, Jelani, mobility of the terminal ilium. Let's double check. I just don't want to be greedy. I want it to be a little bit more kind of scholarly in this because in patients with whom cecum is a little bit more fixed, a TI is not mobile. So we'll just take a look. So have a boom up and down the camera. Boom. Up and down. And see which we are. So this is gonna size us up. So remember what our goal is? Remove the colon, number one. We already performed a high ligation by dividing the colic. And then can we give the patient a little bit more paralytic? Would be great. Thank you. You can see I reach for the colon anastomosis, the answer is probably better would be to release a little bit more, okay? Can you do some? Yeah, yeah, yeah. Yeah, yeah, yeah, yeah, yeah. You see, Jelani, so the thing is, when we exteriorize the bowel and you're like, "Why is it not reaching?" You're pulling it. Yeah. Unfortunately the patient's not paralyzed, and... So here what I like to do is I like to use blunt here. Show me down. So this is the step that we oftentimes like ignore because you know, it's not as elegant as other steps. You know what I'm saying? And we say, can we just ignore it, avoid it? You mean mobilizing the...? Yeah, yeah, yeah, yeah. And the thing is, this is the step that creates extra aggravation or let's say, Jelani, you're doing appendectomy, okay? And appendix is not coming, and you need to do this. And you'd be like, well, this is another extra step. Yeah. And I argue to you that this is the step that gets your appendix done properly. You say you spend half an hour, 45 minutes, add to the operation, mobilize the TI and the cecum, and suddenly, appendix is now in view. You can actually properly visualize the base. Yeah. So it kind of translates to all kinds of operation. So let's see. This is cecum. Yep. This is... We're gonna run the TI a little bit more and see if we're reaching. I am trying to find out our insufflation. What is our...? Our insufflation may not be working. So can we check? It's pretty soft. Yeah, it's zero. Okay, so this is deep. You see this is too deep. Yeah. Yeah. So this is where we need to be right here. So in order to, for us to properly get the colon up, we need to make sure. So you don't want to be here. And that's just the matter with staying right on the colon or...? Right. You'd have to stay right on a colon. But when you have a medial-to-lateral and you've already dissected... Yeah. You can actually use this, this plane as a way to set the plane right. So... Okay. So let's go back. I wanted to see if I can free up a little bit of this stuff. So as I told you, Jelani, this is where you have to be very cognizant of the duodenum because sometimes you feel like, oh, it's too far. Right. The duodenum can be very, very close here. So little vessels, if you don't have to chase them, don't chase them. So just put it back on and say, pretend it doesn't happen, okay? We'll deal with it later. Okay, we'll take a reverse Trendelenburg position. We'll switch again. So if you get a little retroperitoneal kind of, it's not like a pumper, it's more of a bleeder kind of oozer. So then, okay, now let's get another grasper. We take the flexure down. So we mobilized everything. So now, the colon is, see, mobilized here, mobilized there. We wanted to make sure we did what we needed to do here we'll revisit this a little bit more. Now we just need to take the flexure down. So a little bit more reverse Trendelenburg. So the way we do it is this, Jelani, we're gonna... Omentum has to come down. We don't need to be so far by the stomach, we just need to be by the gallbladder, okay? So come in a little bit with the camera, grab this part and just retract it towards the patient's left toe, okay? Now, here, we just have to free it up from the gallbladder. The same thing, you know? Sometimes we as surgeons feel like it's such a big deal to take the flexure down. We just don't do it. And I say it is a big deal, but if you do it smartly, it actually changes everything. Let's say you do ileocecectomy or you do appendectomy, and you feel like you really need mobilization, and things are not good. And it's a huge long retrocolic appendix. You know what, yes, it's a big deal, but if you just do it smartly, it's safer. So look, hepatic flexure, the hepatic colic ligament is very, is very, very, very vascular, okay? So we have to be aware of the part that I... So there are people that do this operation without taking down the flexure. No, not this one. But I'm talking about, you know, sometimes you do - see this duodenum here. Yeah. Very close. So sometimes you do this operation, Jelani, and you try to do ileocecectomy, let's say for IBD or appendectomy. And you feel like taking hepatic flexure is such an adventure. Yes, it is. But I also will tell you that, same thing, oushing down. Pushing down, okay? So go ahead, switch. Just kind of work the same way. The usual way, okay? Say it again. Flow is great. Yeah. And then go ahead. And now this one you have to cook, okay? So remember stay low like we talked about it during the colon. Low means posterior, okay? Don't lift up, just dig in. Dig in. That's good, take it. Go, go, go. And immediately start pushing the colon down after you're done, push down. The tops. And then divide next. Roll it into it. So your hand, whatever it's doing, you can grab it right here. So you can roll the colon towards you, okay? So whatever your hand is doing, you can grab it right here, okay? And roll the colon towards the, everything has to go towards the left toe. Nope, flat. Put it flat. Flat and down. Good. Good, that's it. Now rotate your Enseal. Get in and rotate it 45 degrees. Just push down colon first, and 45 degrees the other way. So it makes a turn the other way. The other way. Yeah, that's it. Good. So you see them turning. Pull it towards you. The entire unit on the left hand, left hand has to pull towards you. Good. Again, close your instrument. Push everything down 10 times, patience. That dissection, Jelani, helps so much. Okay, go ahead. Now divide, push in side to side into the hilt. That's it. Boom. See how it's coming down. So remember left hand working towards you. So left hand has to retract. So open it wide, as wide as it goes. Lower down on the colon. Gently close and retract the whole unit towards you. Good. That's it. That's the plane we used before to just get into that. Remember, don't lift up until you're ready to fire. Fire, you lift up. Before firing, stay low. Okay, posterior. Good. Continue. Good, it's there. Side to side. Don't lift up. When you're getting in, don't lift up. I get 5 cents for every time I said don't lift up. I'd be a rich man. So when you engage in. Exactly, fight the natural tendency. Yeah. So Jelani, when you engage in your instrument, do not lift up, okay? Keep it low. When you closed it, that's it. When you closed it, now elevate it a little bit. And now fire. Beautiful. You see how, oh, gorgeous, done. Let me tidy things up. So flexure is down. So the only thing here, Jelani, is for us is to smartly detach it from the duodenum. If we can. We don't have to, but it's nice to be able to do it. So again, you just divide. And sometimes, I don't even lift up because I'm afraid to rip. So again, this is the duodenum where attachments are. Very quick. Very quick. I wanted to make sure the colon is away from the duodenum, Some of the retroperitoneal attachments just to kind of tidy things up. As I told you, you know what I'm saying? This is final little wisps that will not allow us to come up. And then that's pretty much it. Okay, so the transverse colon we're probably gonna use for anastomosis, should reach up nicely and then... There we go. Yeah. And then the flexture is down, okay? So what I like to do here is show me cecum. Grab the appendix or something like that. So show me the cecum. I'm just gonna grab it. Okay. Okay, so TI you see how mobile it is? Oh, yeah. Goes anywhere you want. Okay, so we're gonna do the rest of the part of the operation using open approach. You can flatten the patient. We're gonna desufflate. Yeah, we'll take large Alexis. You know, usually people say, oh, my god, large Alexis. I'm like, it doesn't make incision bigger, it just makes it easy to work. Gas off. Page can go and then Jelani on the side. Table high a little bit. And we'll take the lights in the room.

CHAPTER 4

All right, so Jelani, we're gonna go down a little bit and see how it goes, okay? Okay. Bovie. Do we have a lap? Yeah. I wouldn't go down so much more. Just to there? Okay, just a little bit less. And then, we're gonna probably extend it up a little bit. That's good. That's good. Just go ahead and divide. Just cut. So we will need a GIA-80 stapler. Blue load, please. Hey small Richardson, please. Good. We'll need a couple of reloads. Okay, go ahead. Good. Okay. I think it should be okay, let's try that. We'll take a large Alexis. Large. So watch, I mean. Jelani, it's like this. So you open it up, you don't have to worry about being large or small. It fits inside the abdominal cavity. Yeah. And just kind of smartly insert it in. Just finds it spot in there. See what I'm saying? Do you like the? What's the event of the large versus small. It just keeps things tidy and it actually stretches things nice. Okay, one last one. Okay. One more or? Actually, let's see if it's... One more, it's fine. But this is it. Can we have two blue towels, please? Okay. So it looks like it's an operation. Okay, can I have a ring forceps, please? And Richardson retractor medium to Dr. Williams. Okay. Just grab it, sir. Go ahead just grab it. Yeah, just grab it. Just one, one tiny little bite so you can stabilize it, okay? Now can I have a Schnidt, please?

CHAPTER 5

So the first steps first, you know like the mistakes everybody makes is just takes the whole thing out and gets congested, now. Now we release it. So we're gonna take, first thing we're gonna make sure we got what we needed to get. Feel it, Jelani. It's right there, it's soft. Yeah. Okay. So first thing first, first thing we wanna do is we wanna transect the terminal ileum. Why? Because we don't want it to drag with us, okay? So we'll take a mosquito, please. Mosquito and you over between the... And I'll take a DeBakey. Just tiny little Bovie. Quick Jerry, please. Just between the tips. One second, Jelani. Okay. Good. Push. Good. Divide. Happy? Happy. Okay. Can I have a 4-0 silk stitch, please. So this stitch, Jelani, helps us to prevent a situation where we spend an hour looking for it. No, mosquito, please. And you can just, clap it. That's fine. Just helps us to fish it out, okay? It's a little life hack, okay? So... Life hack. So you see, Jelani, this is where we were working already. Yeah. So we'll take Enseal. Yeah. Okay. Already showing itself. There we go. Nice and smart. Slow burns. I'm gonna go here. This way. No, you can use the crotch that you already developed. Oh, good. So the reason it's so helpful is once you release it, you don't have the omega, you know, the two end sticking out. You just have one. And that actually allows you to work with just one loop rather than two at the same time. So you don't need it. So disconnect it, drop it inside. Okay. And then focus on the distal end. Good, good. Okay, good. So now this goes inside.

CHAPTER 6

Okay, now we're gonna gently deliver this one. So remember that colon, if you wanted to deliver it, you kind of work the omentum up. Yeah. And then see if you can get the whole thing up, if you can, okay? It's okay. You know, we're gonna... We're gonna use - this going for an anastomosis. Okay, this is gonna be our preferred. Yeah. Yeah, and then with this one we're gonna remove - one thing at a time, okay? So let's... Prepare. Yeah, I'm just thinking about it, Jelani. You wanna go in...? Yeah. This is the... Colon. I think it's reasonable. Go ahead. Yeah. And you can actually Bovie here. Okay, and go ahead and Enseal it first. So we'll have two more loads of GIA, and we will need a TA-90 blue. So one thing we have to keep in mind is that we don't have to do high ligation of middle colics because this is just more for an anatomical consideration where we wanna make anastomosis, you know? Because we don't wanna make anastomosis at the hepatic flexure where we just did - Bovie. Just divide it this way. Good. All right, Jelani. And just go ahead and make, you see, just vertical up and down. Okay, good. A little bit more. A little bit more. Good. Now GIA, please. Okay. We're gonna try to offset it slightly more proximal so we don't, okay? Okay, slide it forward farther in. Go ahead and fire slowly. Good Over there. Slowly. Nice and slow. Good. Thank you.

CHAPTER 7

Okay, so now we're gonna work the... We might need to make incision a little bit bigger, we'll see. Right now we don't need to, but... Okay. Let's do it now so that we don't struggle. Just a centimeter. Oh, yeah, got it. We will take a small Richardson, please. Just there. Yep. Sometimes a tiny little extra length of the incision makes... Yeah, so go ahead, Jelani. So notice the stomach. Oh, yeah. We're not taking the stomach out. No. I hope not. So yeah. We also don't want to take any vessels that belong to the stomach, but notice how colon surprisingly is foreshortened as far as the gastrocolic ligament. Okay. We got into a little bit of colon, which is okay considering that it's a specimen. So let's see. Let's see. Go ahead, Jelani, hold this up. So similarly with this one you'll see what I'm gonna do is as soon as we feel like this is divided enough, we push it in, okay? And then it allows us to create a little bit more room for ourselves. So we'll take a wet lap, please. Yeah. You know, so there's a lot of this. We should make these incisions or this intracorporeal. I say that... If something works incision or anastomosis-wise, hemostat, please? And you, you make a change, and you get a fairly reasonably good outcomes into a little bit less reasonably good outcomes, then you ask yourself, "Was it worth it? Was the change worth it?" So we're just gonna skim around it. Can we have Richardson retractor, please? We'll take a larger one. Larger one. So the key here, Jelani, is to be aware the duodenum is right there. Can I have a DeBakeys, please? So you know like there's always this kind of a rush to get things taken care of here, but I don't like that. You see the duodenum right there? Mm-hm. Yep. So what you wanted to do here is to kind of, without putting too much tension, and again this is not a hepatic flexure tumor, and as a matter of fact it's probably a benign tumor we're just doing... Yeah. Sort of a safety thing. We already divided the vessels. DeBakey. Yeah, and just keep this gastrocolic ligament up. Just checking. Let me just control this one. So this is the most tricky part of the operation, Jelani. Because if you have a colon just attached on the pedicle, middle colic pedicle, and you pull on it... It avulses. It avulsion off the superior mesenteric vein. And if you feel a little bleeding, you just need to open it up and just deal with it. Okay. So... There's not really another way to, because the problem is this, if you try to put stitches or put pressure, you are gonna be big hematoma, right? The head of the pancreas. And then you're gonna be... So another thing is this, if you feel like it's really that's what it is. Just stop the operation. Wait for the senior partner hepatobiliary surgeon to come in. 'Cause the stitch has to be put precisely. 'Cause if you don't put the stitch precisely, you might actually interrupt the flow to the, excuse me, what is this, stomach? Yeah, this is stomach. Oh, we'll probably need to put a stitch in a little bit. It's pretty close. Sorry, Jelani. Yeah, she's very close. Can I have a ring forceps, please? All right, can I have a 3-0 Vicryl, please? One second, Jelani. One second. Is there an area that looks questionable? It's not that big of a deal, but I think it's right here. Hold this up. Right angle, please. Bovie. Bovie. Just a little bit more. Actually, I'm gonna do this with Enseal. I think it's okay. I just felt a little, I felt a little thick. So Jelani, the reason I wanna do it while we see it is because if we don't cook it or we don't address it, we won't be able to see it after we finish the collecting, okay? So let's look at it. I think it's... I think it's okay. I don't see anything concerning, do you? I don't see anything, no. Let's take a look. It's fine. You see how close it is? Yeah. So the colon and the stomach are like really, really close. So let's just use this one to keep things apart. Okay, so Jelani, why don't you do this? Why don't you hold this with the... Hey and we are gonna work on this one. Because I want to release this first. So hopefully it's just the specimen side. Okay, so what I did is, as you know, the hardest part is this one here. The button right under the stomach. Yeah. So I released this stuff here. Can I have a wet lap, please? So I'm gonna just... Put that down. Yeah. Typically, the gastrocolic ligament, which is the distance between the colon and the stomach is at least five centimeters. Especially with the amount of inflamed bowel. Hers is not that long. No, not at all. So we really are skimming. You lift it up a little bit, Jelani. Lift up the whole thing. Okay, hemostat, please? Good. Good. All right. So here it is. Now we can see the colon. We can see colon, we can see the stomach. So sometimes when you're digging into the hole and things are not looking good, the best thing to do is just to free up proximal or distally if you can. So notice I put the lap so that whanever I'm Ensealing, is the lap, you know? I am gonna look at the duodenum one more time. And the, okay, so this is the specimen. So can we have a blue towel, please? Do you open it up to make sure you got the...? It's pretty obvious. No. They yell at me for opening up because I'm screwing up their anatomical landmarks. Oh. So this is appendix. Feel it, Jelani, right there. Take your time and just feel it rolls in there. Fortunately, it feels benign. So this is specimen: right colectomy. Right colectomy for routine. Yeah. For routine.

CHAPTER 8

Okay, Jelani, let's look at it one more time. Okay. Hey, can I have a 3-0 Vicryl, hold this up? I think it might be. Right there. Now that it's better exposed. I think this thing flopped down. Yeah, I'm just gonna reinforce it. I don't know what it's gonna be but scissors, please. We're safe now. Needle down. So one time I was doing the omentum mobilization for the APR, and I was skimming it between the gastroepiploic and the edge of the stomach, and you know those little vessels, the straight vessels? Yeah. And I tried to divide them, and stomach was normal and thin. And the guy winded up perforating, postoperative period. Scissors, please. Okay. All right, Jelani, I think we've looked at this. One second. Just regrab here. One second. Give it a good tug. I think that's good. And when you have to look this hard, that means it's probably not a problem, okay? All right, so now we can take this out. Take this out. So, let's look at the duodenum one more time. Richardson retractor. And you say, you know, like you do this laparoscopically, why? And the answer is you can't take the flexure down through the incision like this. No, no. So, okay, that's fine.

CHAPTER 9

So let's now begin. So now we have to pull this up. And again this has to be oriented. So one of the biggest mistakes we can make is we can, if we're twisted. So hold this up, Jelani. Can we have patients steep right side up, left side down, please? And that's good. Thank you. And I'm just here. And then we'll take a sponge stick. Okay. With a sponge. Okay, Jelani, let's see. Can we give the patient a little bit more paralytic would be great. Thank you. So how do you confirm? So the way you confirm is this, you need to see the straight edge of the mesentary going straight down towards the duodenum. Nothing in its way. Ah, ah. You haven't seen the duodenum yet. You gotta see it. So, that's it. That's it, Jelani. You have to pull. You see how stomach is laying in there? Yeah. It's crazy. Crazy, stomach has been participant in this operation more than I like. Right there. You see the duodenum now? Under the liver? Yeah. Way out there. Now it's for sure. So never skim through this step. One time when you will have it. So Babcock, please. So far so good. Okay. Okay. Another Babcock. Okay. Okay, so we're gonna have to prepare it a little bit, Jelani, but... Okay, so... Just amputate this stuff. Okay, so I'm gonna guide you and you're gonna... Mosquito, please. So you can use Enseal if you can. Bovie if you can't. Pinch buzz. Sandy, can we turn the temperature? That's good. Just one quick... Can we turn the temperature down by five degrees, please? Huh? Just by Bovie. Pinch buzz. You've been with Dr. Hurst? Yeah, that's good. Good. So just go ahead and amputate a little bit, just Bovie. Good. Okay. Okay. Pinch buzz. That's good. So this is not the mesentary. Now this one is our take with Enseal. Bovie. Okay. Enseal if you can. Good. Pick it up with the pickups. Good. Yep. And that's it. Quick ones, quick ones. These vessels are small but they're pesky. Bovie. That's fine. If it's clear, Jelani, Bovie will take care of it. Because Bovie has ability to coagulate vessels, you know what I'm saying? Now pinch buzz. That's good. All right, looking good in the neighborhood. So now we're gonna do it here. Scissors, please. All right Jelani, we're gonna free it up here as well. It's kind of a landing site for - just Bovie. Okay, we'll take the Bovie down by five, please. Thank you. See how it's arching. Bovie down by five, please. Pinch burn. That's good. Thank you. All right, Jelani. I think it's pretty good. Can we have two wet laps, please? We will take one more, please. And we'll take curved Mayos. Keep things tidy. So we'll take curved Mayos. So Jelani, what I'm gonna do, I'm gonna start here, and you're gonna do the next one. So antimesenteric border, and you cut right under the staple line. You don't have to take the triangle out. And I cut kind of generous cut and you'll see why, because I'm taking the entire staple line off afterwards. So we'll take the DeBakeys and we'll take Babcock back, please. I'll take the DeBakeys, and Dr. Williams will take the Babcock. Just go ahead and grab it. One click. Good. Now go ahead, Jelani, do the same thing here. Antimesenteric border. Just see the staple line? Just cut. Cut along the staple line. That's too small. So, don't rush, don't rush. Let me show you. So visualize the staple line and just cut along it, okay? Slow steady movements. Just cut. Good. Good. Just keep cutting. Keep cutting. And you want that... Keep cutting a little bit under the staple line, yeah. See the staple line? Mm-hm. Cut it. Okay, cut up now. Good. But now we'll take the DeBakeys back. Another babcock. The reason for that is you don't wanna struggle putting the stapler in, okay? We'll take a GIA stapler taken apart, please. Before we do this, let's control this - what Jelani noticed, a little oozing. Okay, all right, now small into the small bowel. Large into the large bowel. How simple could it be? So go ahead, follow the bowel. Watch where you going. Good. Good. Now we'll take the Babcock off. Do the same thing on the other side. See how easy it goes. Beautiful. Take the Babcock off. Now make the stapler. Okay, remember... Okay, now, slowly close. Patience. Okay, now, keep the tips of the stapler down instead of up so you don't engage this thing. Maintain them in one place. Go ahead and fire, okay? Okay, pull back. Good. Open it up. We'll take two Babcocks, please. So Jelani, we're gonna take one Babcock on one end of the staple line. Then you see the end of the staple line here. DeBakeys, please. No, no. We'll take all of the Babcocks we have and all of the Allises. Okay, so... Okay, Jelani, so go ahead and grab the end right there. Beautiful. Now we're gonna pull it apart. Take another, Babcock. So I like to match the staple lines. They will have set on their own. So you don't have to worry about offsetting it. Just match it, making sure it's slow, okay? Next stitch. Excuse me, a Babcock. So the key is not to miss the serosa. Serosa. Yeah, that can do a lot. Do you want these bigger? Doesn't matter. Okay, so, okay, Jelani, now you. Like look on both sides. Make sure you don't miss the serosa. See how you're missing it? It's right there. That's it. That why we use 80 is because we have room, okay? Okay, go a little bit lower, make sure it's safe. Good. Go ahead. One more. Yep. Just mark it. Mark the staple line so we don't miss it. Like that? It's fine. Okay, we'll take a TA. Okay, so... Okay, start by... Hmm, go ahead to pin down first. Pin down. Good. Now slowly close, slowly, slowly close. Go ahead and close all the way. Good. Just wait a second. Don't do anything yet. So this is the period we give tissue to compress. Now, Jelani, one of the things that you can imagine, the small bowel could be thinner, the pole could be thicker and you're firing one staple line. So it's nice to give it a little bit of period to compress so that the staple line forms equally on both sides, okay? So now squeeze the handles fire and just hold. Okay, good. Now, cureved Mayos to Dr. Williams. Okay, and just cut the staple line. So you'll feel the crunches in the middle. Crunch, crunch. Just go cut. Cut, cut. Cut, cut. Cut. Okay, good. So now go ahead and open. So we don't burn it. I don't find it... You don't. It's not humane to burn the bowel. Very good. Now... So the purpose of this, Jelani, clearing up the me mesentary, here and here is when we take out the entire staple line, which we just did, you see it comes now to the staple line. And we've gotten close to the mesentary here. It's bleeding a little bit but it's okay. We're just gonna put a figure of eight, and we're gonna dunk it, okay? Okay. But you see the anastomosis is just the right size because we took it down. So we'll take a figure of a 4-0 silk stitch, please. Left? Mm-hm. Okay, short DeBakeys, if you need them. So just put a figure of eight. Just control the bleeding. A little bit closer to the corner. I think it's bleeding from the corner. Take your time, Jelani. A little bit farther out like this. Good. Okay. To pops? Pops. Needle back. So now look. Now we have the corners that are potentially weak spots. Not that you don't trust your staple line, you do, but it's not designed to be completely hydrostatic, okay? So I like to reinforce them. This is kind of my preference even if I have to just bury them in the mes. Yeah. I think it's safer. Stitch, 4-0 silk. 'Cause you see the serosa is way away. This cut kind of extends out. So I try to do a very smart bite. I know it's crazy, but I feel safer just burying it rather than leaving it. So as long as you don't take the vessels, you should be okay. All right, Jelani. So dunk it in. Good. You see what I did? Yeah. I just draped it. Why? Because think of the way the staples are designed, they're designed to let the blood continue to flow. So they shouldn't be super tight. But in kind of, you know, forming those bees, they sometimes let a little bit of air and a little bit of juice come out. And that corner when it kind of juices out some stuff or puffs out some air. Yeah. That's the corner, Jelani, where you can have a little small bowel stuck to it or a little this or that. And then you could sometimes see the ileus, which is like, why would the patient have ileus. Case went well. Just a little leakage from the corner, okay? All right. So tie this one, I'll see if we can shove it in. A second, Jelani. Mm-hm, just hold for 10 seconds. Okay, we'll take another 4-0. Good. Scissors. Corners. Corners. Now this is what we call a confluence of the staple lines. This is a very compromised kind of area because you took it down all the staple lines. So this is how I control it. Jelani, you might remember we've done it before. So this is kind of a horizontal mattress stitch on this side. Come across the staple line and make my way back. So actually, it inverts it beautifully. So, okay, Jelani, here's what you do There's just a lot of tissue to bring together. So just when you throw a knot, hold it for 10 seconds. Be patient, okay? So one second. And bring it together. Just tie the knot. Apply constant tension and just don't jerk it. Just hold it there for 10 seconds. So the tissue will accommodate. And when you throw in the second knot then one unravel. Good. So now you saw how it all gathered together. Scissors, please. Stitch to doctor. So Jelani, you're gonna put crotch stitch, okay? Just a regular Lembert, okay? You see where those staples are? Just below it? Yeah, I'll show you where I'd like it to. So you see how that right outside the staple line? Mm-hm. Mm-hm, that's it. He says that it's not critical right now. You can call back later. Sounds great. Thank you very much. Scissors. So, Jelani, corner. Corner. And then you do that one. - One staple line. If otherwise the anastomosis looks okay, this is all, if you worry you can continue with Lemberts here. Yeah. But it looks fine. And then crotch stitch. And the one here that you did, the first one was just this one. Just to get this. So the figure of eight.

CHAPTER 10

And then another thing, sometimes when I'm still a little worried, I'll take the Richardson retractor, and I'll take the sponge stick with the sponge. And I just wanna make sure the mesentary... Look at the mesentary. Yeah, yeah. So the reason for that is because when you have, if you ever have a twist it doesn't present until much later, then it's - could be a really devastating. Lift up a little bit higher. Very good. You see how it's kind of running smooth? Yeah. And nothing's crossing. So this bowel is out of the way on the other side. And this is running towards the duodenum. So, and she's pretty high up if you think about it. So this is it with bowel anastomosis. Can we have some irrigation Poole-tip sucker, please. We're gonna change everything. Our gloves. Here on out. After we irrigate. Okay. So, I disconnected it. So for the Poole-tip sucker, it's better to use this one, the big one, okay. Or we're just gonna go right up a quadrant. Rich, big Rich. Use only, ah... That's fine. So it looks pretty pretty clear. Yeah. So we're gonna be closing if possible to give the patient a little bit more paralytic would be great. Always in the pelvis no matter where you do. So we'll take the retractor off. So I know this stretches it pretty hard. Yeah. But the, you know, and that's what I like. But we'll save it for just a minute. But once you release it, the incision winds up being reasonably manageable. So we're gonna close with all Vicryls. And we're gonna use fancy stapler. I like it better than Sub-q closure because I don't like to have incision completely shut. Now I realize we should have tilted the patient. Can we tilt the patient toward Dr. Williams? All this time you were like this. And I'm like, I'm enjoying it. Can we tilt the patient a little bit toward Dr. Williams?

CHAPTER 11

Good. Skin bleeder. Opposite side. Burn by attending. We'll edit that out. I don't know. Keep it. Keep it. Rub it in. I can take out VOG. Ah, yes, please. Mm-hm. Okay, can we have another Kocher, please? You did that one. Yeah, just how it's supposed to be. Draping. Another Kocher, got it. But you're not a fan of omentum, right? No. Hate, hate. It was a prehistoric relic. Yeah, in a modern world we don't really need it. It's an enemy of surgeons. It sticks to everything. But you know what? Taking it out for no reason can bite us in the ass because then it bleeds, okay? You know, I don't know exactly why we have it, but I think that the kids who had it, as I told you, the kids who had it... Survived the appendicitis. Survived the appendicitis, and then passed on the gene. The kids didn't have it. Did not survive appendicitis and died. Well, we got the Kochers. We just need to have an 0 Vicryl. Oh, oh, thank you. And if the patient can get a little bit more paralytic would be great. We are gonna close it though, Jelani. Yes. But... I got this one. So you can just lower that one a little bit. And just gimme a little exposure with the retractor. Okay. Large hemostat, like a tonsil, please. Stitch, please. stitch, please. You can ease off a little bit on the instrument. That's good. On the Kocher. Just kind of little bit less tension on the Kocher. Good. Okay, hold on one second on the stitch, we're gonna switch to Dr. Williams. Line is gonna be a little bit farther in, but you'll find it. Medium Richardson, please. Dry lap, please. Oops, sorry. Stitch to doctor, please. Good job. Good. Needle back. So I mean, if you look at the clock, I don't know what time it started. 8:00? So we we're finishing up within... This is a good time. I've been reasonable, you know what I'm saying? I'm not into the skin to skin action, you know what I'm saying? Yeah. Large hemostat. I just think that the operation should be optimal. You know, like if you think about operation, it shouldn't be - ideally, right colectomy but otherwise is not - only complicated patients should be six hours. Let's put it this way. You see what I'm saying? So how do you do it, Jelani? Is you tailor the operation to your skillset, to your patients, factors, to the patient's wishes. Needle back. And just do it. Do it right, you know? So a three-centimeter longer incision is not gonna determine the patient's outcome. What determines the patient outcome is what you did on the inside, how precise you are with what you've done. And then if anybody feels that they should be impressing other people with the length of the incision, they can do it, certainly. So when you think about it, I mean, statistically, most surgeons will tell you that after this type of operation, the leak rate should be zero. Zero? Mm-hm. Just like with a small bowel resection. Yeah. Needle back. If you have a leak, a patient has a leak after small bowel resection, you ask yourself, have you done the proper operation or have you made the right decision about making this anastomosis? Yeah. You know, so... And in controlled circumstances, if everything goes well, the rate of the leak for this should be zero. Now if you're operating, and then you ask yourself, let's say fortunately your outcomes are good, your leak rate is close to zero, and you say to yourself, "Do I really wanna make a change?" And my question is, you know, like you, you have to go through your internal needs analysis, asking yourself, is the change needed? Right. Just because the change is available to you, do you want to embrace it, accept it? And then you say, "All right, well, okay." So what can happen is that my rate of leaks can change since this cannot change in the getting better. It can only change and getting worse. You don't know until you try and you say, "How many patients with a leak, will it take for me to justify changing things or making anastomosis intracorporeal? And the answer is, I don't know. I don't think - there's no number needed to treat here. Any and every leak is unacceptable, if you know what I mean. That's why you wonder why am I doing what I'm doing is because since fellowship, I've had reasonably good outcomes. So let's ride them. 1, 2. 3, 4. 5. So this one is always, you're traveling back a little bit. Jelani, you notice this is a natural tendency. It's fine, take it. But keep in mind that the other one, you're traveling towards you, the other one is almost always away from you. So it's a natural tendency, just work on it, make sure it's perpendicular. 1. So notice this one is a little bit longer because you travel less on this one, okay? So just compensate, okay? Yeah. Yeah, travel more here. Correct. And the reason for this Jelani is because your natural tendency is to always take a bite forward. Try to take a bite towards your belly button on this bite as well, okay? No, no don't tag this one. Hemostat, please. Hemostat, reinforce it. It must be of some sort of emergency. Do people understand that surgeons actually...? I think it's just a mutual patient. Yeah, that's fine. That's fine. Can you call 'em and tell 'em that I'm scrubbed in the operating room? And I will call 'em back as soon as I'm done. Thank you. Oh, that bellybutton. Travel just a tiny bit less. Thanks, Derrius. Good. Okay, hemostat, please. Okay, stitch, please. So I'm gonna do it from the side. We'll take another ring forceps and another... Well, you know, the final steps were not as clean as I like, but usually it just kind of, especially in the woman, the anatomy is such that everything is a little thinner and mobile. I don't know. Stitch, please. Stitch, please. Can I have another stitch? So let's put them... Here's the needle. Stitch, please. Just one. Just for good measure. Now no matter the size of the incision, you always do interrupted, right? I don't. Many times, Jelani, I do it with - needle down - I do it with the running. But when the small incision, I feel like it's much nicer to do it with interrupted. So that - needle down, we're done for right now. So now make sure you string it, okay? So string it. Mm-hm, yeah, down. One, two, three. Okay, clamp both of them. So they're not in the way. Needle down. Fascia's closed. So we're gonna staple the skin, we're gonna close the ports with sub-q stitches. 1, 2, 3, 4, 5, 4, 5, 6 , 7, 8, 9, 10, 11. Okay, we'll take some irrigation. Bulb syringe. Bulb syringe irrigation. That's good, we'll take a dry lap. All right, Rihanna, we'll take a 3-0 popoff, but if you don't have 'em, we'll take a regular one. Adsons, please. I'm sorry Adsons. Kind of deep supporting sutures just to help to bring incision together. But on the thin patients is not super critical. So the key here, Jelani, when you're doing this fancy staple thing, is not to put stitches too superficial. So I'll show you one more and then... Okay. So you see this deep? Yeah, saw deep. Yeah, don't do, because otherwise you won't, you won't have the stapler fit in there. For this particular incision, it's tricky. So if you ever try to do it in your earlier cases, don't do it 'cause it's gonna be a mess. So let me see. Insorb. Okay. Fancy stapler. Or in the meantime, we'll take a 4-0 Biosyn, please. All right, Jelani, here we go. Scratch ready. Scratch the thing, but don't, yeah. Yeah, yeah, yeah, yeah, yeah. You see how beautiful it is? No buttonhole. No buttonhole, that's fine. Thank you. Scratch this side. Yep. Shoe string. Parallel to the skin. Parallel to the ground. Make sure it's on the same side. Aside from bleeding, this is a very good technique because it, it lines up the incision perfectly. 1 scratch pad is still up. Bovie is still up. Okay, let's switch. I'm gonna hold pressure and you're gonna close the other ones. Can we please have a Steri-Strips cut in half, something wet, something dry? Your second and final count is correct. Thank you. So see, Jelani, once it's all said and done, if it's closed up nicely, it looks neat, you know? Ster-Strips, please. DeBakeys. Thank you. Okay, another one, please. Good, thank you. Needle down. We got a wet and a dry. Okay, so we'll take a Dermabond. Can I have...? We'll take some Tegaderm and some dry gauze. Look at this, Jelani. Small one or big one? Tegaderm, big one. Pop-Tart size. Pop-Tart size. The thing about it, how the size of the Pop-Tart became like the measure. I mean, in France I'm sure they don't measure things in Pop-Tarts. Have you eaten a Pop-Tart? Unfortunately, Sandy. They're not bad. Oh, that's the problem. They're not bad. Have you looked at the back, Sandy, what it says? I only eat one. Yeah. Not the whole pack. Yeah, I only ate one every 15 minutes for my entire residency. Okay, can we have something wet, something dry, and then we'll have a 4-0, can we have a little gauze? Yeah, well, 4 by 4 gauze, just a dressing gauze. Some patients have hypertrophic scars and some patients have keloids, but even in dark-skinned individuals sometimes it's just like a scratch. That's what I like about it. Jelani, hopefully, you'll come to clinic. Yeah, I'll see, yeah, what the end result looks like. Another one, please. Okay, Pop-Tart sized. Beautiful. See, perfect size of a Pop-Tart. Stays for a couple days. Yeah. You can take it off. Let it open to the air. Good, man. Thank you. We'll take the drapes down. Thank you.

CHAPTER 12

All right, so Jelani, we're gonna go over this case we did together just recently. This was, as you remember right hemicolectomy. There are several steps in the operation. The entry, the initial dissection. The exteriorization, resection, and then the anastomosis and closure. So we'll kind of go over those in steps. So let's just start playing and we can scroll to the next step. So we see the outline of in the event that we will need to make a laparotomy, then the midline has been on. The other thing is this, as you remember, since we're planning on doing extraction site, a mini-laparotomy at the site of the belly button, the size of the incision is not as critical. So we can make it fairly generous to get an easier access. So let's scroll to the access. So here's a... You did this part really well. There is no question you know how to get in. It's a Hasson technique, you've done that's with gallbladders and things like that. So there's not really a lot of discussion here. So once we get in, so, the choosing of the ports. So here is the suggested port placement based on ergonomics, depending on the size of the surgeon's hands, but somewhere between eight and nine. Currently. You wanted to make an equilateral triangle here. And what I was trying to tell you is if you base on bony landmarks, sometimes you find yourself with being a little too lateral. And being to lateral is not an issue with the reach. It's more of an issue with the fulcrum effect. If you wind up using a lot of instruments, that most of it inside the patient, then a lot of the fulcrum effect winds up being too close to your hand and then you have degradation of motion. Alternatively, if it's too close to midline notice, then you find the working straight up and down, which is also ergonomically not favorable. So it's ultimately gold deluxe about eight, nine centimeters, about a fist's width. And then you just make a triangle. And I think this applies also for operations like appendectomy where you feel that you're just working into the right lower quadrant. So this is where we are. So to begin, ideally as you remember to do a medial-to-lateral dissection, you need to visualize the second portion of the duodenum through the retroperitoneal coverings. And omentum is barely obstructing this view. So in order for us to try to get the medial-to-lateral, it's good. Now you see how you're grabbing here. It's a very good efficient technique because when you're thinking about maintaining traction, you don't want to regrab too frequently because it slows down your progress. But also you want to make sure you always have an optimal tension on the tissue. With Enseal, it's an interesting thing because you do need tension to present the tissue to yourself. But at the moment when you're dividing, your tension could be counterproductive because the tissue might separate before you complete the burn cycle. Did you relax a little bit of tension that sort of thing? So kind of easing a little bit of tension, you can still maintain the exposure using tension. What I also like about your technique is that you're trying to avoid this natural tendency to elevate the instrument. Yeah. Because we all feel that there's something underneath that we don't wanna burn, even if there's nothing, we're just so trained to always lift it up that sometimes it gets in the way. You see the attachments. And so what's the question we have is sort of determining whether we are gonna go medial-to-lateral or lateral-to-medial. Partly because the exposure here is not typical, it's not favorable for us to clearly see the landmark, which is the second portion of the duodenum. So the pedicle is visible. And I'm kind of demonstrating it here. And so we're gonna try to see if we can develop a plan, okay? So this is the point I'm gonna get you started. So the key here is that when you get under the pedicle, and you divide and open up the peritoneum is to give it a little bit of time for the CO2, it's pressure is 15 millimeters of mercury. So it's not a small pressure. Yeah and you know we talk about it, if you let's say waste the port and incorrectly place it retroperitoneally. You can clearly see you coming into a lot of Rice Krispies. So you know that there's enough pressure to dissect. So use the pressure to dissect. Dissection, yeah. So yeah. So now Jelani it's you. So let's see how you do. So first step you're gonna do is you wanna make this opening larger. So a little hesitation, a little, you know? But the movements are good. Here, Jelani, you see how we talk about making a motion that looks like a "C", the technique, rather than a down motion, okay? Good. So it's working just initially only on the peritoneal edge, not on the deep tissue because you don't know what's behind, okay? So now the technique is very good. The movements are smooth and small, I like it. So here Jelani, one of the important steps is not only move through your retroperitoneal but also ask yourself constantly where's the right plane? Is it up? Is it down? And constantly adjust. Because if you say this is the right plane, and if you are mistaken, and you just keep plowing through it, then you might find yourself either in a mesentery or in retroperitoneum. So now we are kind of using the two instruments to open things up for you, asking you to just continue with this retroperitoneal section. Okay. So you kind of see the vessels that run a little bit more parallel. They're likely to be retroperitoneal structures, and the vessels that tend to, we call it red radial, alright? Belongs to the mesentery. This is perfect, this is a good move. I would go a little bit more down and keep your instrument closed. And here I would go in a little bit deeper with the left hand and push up, in and up. With the...? Correct. This is a very, very good use of the instrument. So now I took over why? Because this is our frenemy, the duodenum. Yeah, yeah. So the thing about duodenum is you know, it lacks the serosal, formal serosal covering. So it's a little finicky. And so here by using the same sort of push down dissection technique, you could actually potentially damage the duodenum. So you can see it's right there on the surface. So, but it's not because you know, your technique, but was with this it was kind of a critical part of the operation. So this one also I do because the dividing of the vessels and this whole Enseal, it's something that's a little tricky. So if we do this operation over and over again, and you become very comfortable using this device that residents do. Sometimes, you know, one time when we divided, and it didn't seal, we call it a Bellagio. It was like two streams of blood flying actually this... In the woods. Yeah. Well, taking that pedicle with Enseal, It's probably at the upper limit of what the Enseal can do. That's why I'm saying you know how they tested for the FDA, and they say like up to five millimeter but it's a little bit more than five millimeter, and it's a pretty powerful vessel, so. So once we divide this vessel, the next step is to do the lateral dissection. So now we are moving into the lateral dissection. So now we move into this position where I am holding the camera and assisting, and you are doing the lateral. So good job with retraction. And I love this sort of dissecting detail. Remember this hand could have been yes with medial-to-lateral, correct? And then you dissect just enough to allow you to divide the tissue. Once you dissect it enough you can go ahead and divide. You didn't use heat here, right? You just cut it. You don't have to. If you see the blood vessels that are not there, it's just a pure, remember this is the line of biologic attachments. So you don't have to... Should be avascular. Yeah. But sometimes if a little oozing bothers you, you can just do down here. Another thing, Jelani, this is a common mistake, not a mistake but common nuisance. And so freezing the the handle you allow the instrument to jerk instead you just need to focus on, and I know Enseal is not an ideal device, but squeezing the handle should not result in an instrument moving, so... And here Jelani, what I'm showing you is the following. When you're going up towards the hepatic flexure here, you oftentimes just get carried away, and go a little higher than you have to. So, just when you feel like you are at the reach of the instrument, you can stop. So this is too deep, you see? But I'm showing when you see this deep, remember how we talked about during the case, look for the ureter. On the right side, if your planes are accurate, you don't have to look for the ureter. But if you feel you're looking at the sulcus, you've gotta have to look for the ureter, so... And I don't know whether we found it in the case, and I'm not familiar. We're seeing this that I remember for sure that we looked for it, okay? So now let's focus here. So look, I started off by showing you what our goal is. So here you see the gallbladder, which is our reference point, and this is the hepatocolic ligament. You begin by identifying a plane where the colon is kind of visible, okay? So, a critical point here, Jelani, you're controlling the flexure, and the retraction again is critical here, it's essentially to the left toe. Now notice the direction of your Enseal. You see how it's pointing up. That's again common mistake. The Enseal should be pointing or device dissecting device should be pointing parallel to the tissue. And you can always lift it up at the very end. So that's a good dissection technique. Very nice. So you would rather... You see how they're aiming up. So if anything, I would say, to fight this natural tendency to always lift up, work it down and then once you're ready to fire you can gently elevate it. Okay. Good. So this is almost, flexure's almost down. So... Oh, camera clean. All right, so now we, you finished that segment. I'm gonna just do a couple more additional dissection. You can see the second portion of the duodenum this is the stomach. And I felt that we needed a little bit more mobility because we do external - extracorporeal division of the vessel and the anastomosis. That's why I needed a little bit more. Yeah, so this is a good view. I think this is kind of right before we finish. I think this is, you know, like in my opinion the limitations of what we do. And you know, the fact that we have to divide the vessels, we can divide some of the vessels laproscopically, and it can make incisions smaller, but - that's the technique I use when I'm thinking about switching to robotic technique and then doing everything robotically, including the anastomosis. So this is kind of a part that you could have done laproscopically, but I don't feel it's a huge difference one way or another if you're doing open already, okay? So good technique, everything is fine. So got a good anticipation. So we're just doing some final divisions of mesentary, and sometimes at this side of hepatic fracture, more's exposed. The blood build up in there. You just have to... This is the final divisions here. Okay, so that's the specimen is out. So first step as you remove it, Jelani, is to assure there was no twist rotation. Right. Straight on. So all the way to the duodenum. Duodenum. Yeah. The terminal ilium is out. Okay, now colon is out. Now colon is fixed in place so it's not easy to twist. It's almost impossible to twist. So it just comes out straight. Now you line it up. So... Marking the corners. The corners you want. The antimesenteric border of the small bowel. And colon doesn't have to be one particular corner, but the one you think is gonna be better to fire. This is good technique. We're clearing out the mesentary border because when we complete the anastomosis, we don't want to incorporate any mesentary in there. Here it comes. Beautiful, it fits. Have you had the stapler dissecting too low? Or no. It's very hard to do it. Yeah. To strip mucosa, you have to have a special talent. So now make sure that it doesn't have to be.... But the key is making sure the mesenteric borders of the bowel are out, which is fine. And then, gently push the stapler in. Now the natural tendency also, Jelani, is to tip, tip, tip the stapler up as you aim it. So once you close, you pause a little bit, allow the tissues to accommodate, squeeze whatever edema might be, and then making sure what you're doing it right now, which is well, don't force it down, don't force it up. Kind of stabilize it in place. And you know, with this stapler, with a linear GIA, it's very complicated because it's stiff. So yeah, just requires a lot of control to make sure it doesn't go in, okay? So we're getting close to the final steps of the anastomosis, which is closing the common, not common, but the entire transverse staple line, marking it with either Allises or Babcocks. And then making sure that we don't miss any part of the staple line so we can redo it completely and do the TA. And that's you. So here what we're focusing on is how a needle enters the tissue, it has to be perpendicular. It's pretty good. Even though it's obscured but it looks good. So here, Jelani, you notice we lost the tissue, which is fine. I think it was the second part. That's fine. Looks good. You just did it all in one. So ideally you wanna hold everything in your hand. And if you're telling yourself it's fine... So now we're gonna irrigate and close. Then you do the interrupted. Watching you tying. Good technique. Very nice. Very nice. Good instrument handling, the thumb is not too far in, which is a common mistake. Good positioning, stabilizing the instrument with an index finger. The technique is excellent, now you can see it yourself. So it's really nice. Okay, we're gonna continue closing. All the interrupted sutures. And then we're getting closer to the end. We might just use clamps to just collect the sutures. Closure.