Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, greetings to everybody. Uh Good afternoon, good evening, good morning from wherever you are joining from and welcome to the Zoom Academic meeting of the Department of Pediatric Surgery in East London, South Africa. And uh I'm really uh very happy to uh introduce and invite doctor Arua Obasi. I who is a young and knowledgeable and skillful pediatric, minimally invasive surgeon from ever care hospital in Lake in Nigeria. So doctor I did his M BBS from the University of Nigeria in March 2009 and he was interested in minimally invasive pediatric surgery even during the general surgery residency. He was the first resident to work on laparoscopic surgery in West Africa. And his work is now published in the journal of laparoendoscopic and advanced surgical techniques. He joined the Ever Care Hospital in March of 2 2021 and he has performed several laparoscopic and thoracoscopic surgeries which have been very first in Nigeria and in West Africa. And the list is really impressive pil plasty laparoscopic assisted pull through for Herr's thoracoscopic repair of type C esophageal atresia, uh also of long e esophageal atresia lobectomy for the lung, excision of thymoma and even laparoscopic repair of gal atresia. So these are quite remarkable achievements for a young pediatric surgeon at in the family life. He's a Devo Christian. He's married with four kids and he loves to play the keyboard. So again, warm welcome wa and I will stop sharing and you can share your screen and start your talk. Thank you. Oh, thank you so much for the introduction. So uh I believe you can see my screen quite well now. Yes, we can see your screen and we can hear you. Nice and clear. Please go ahead. Yeah, thank you. Um So I just want to talk about um minimal surgery for congenital anomalies and um how we have progressed in um a third world country and to the um level that we are right now. So this is where I practice, which is hospital leg and um it's a modern hospital, um fully equipped uh it and we are one of um one of the kind in our own region, 165 bedded and with a fully equipped intensive care and uh pediatric intensive care. So that's um view hospital. So this is our intensive care for the unit. So basically congenital anomalies are one of the leading causes of global disease, the burden of global disease and is responsible for a staggering 57.7 million disability adjusted life years lost worldwide. And uh that means a measure of the number of healthy life years that is lost to premature death or disability. And this um ee established metric of, of a pattern of disease in, in the world. So, the burden of these anomalies falls mostly on the low and middle income countries where we have 94% of anomalies occur this according to WW in 2012. And because we have a higher um birth rates, uh we have more Children that are born with uh congenital anomalies each year in the third world countries. So, um over the years and centuries, uh minimally invasive surgery has been in existence. But as we all know, pediatric surgeons, we are among the last people to take up um minimally invasive surgery. Uh and, and developed it to practice to an advanced level. We are quite very young in the market of um surgery, generally, pediatric surgery wise. Um initially minimal, minimal surgery in Children um was resisted mostly. Um usually because uh our teachers, older surgeons, um I found it difficult or more or less were not interested in learning new things I should say. And um most uh procedures, you know, we are not really that were done in adults like cholecystectomy was not very common in Children. So, um they, they really didn't see why uh they, they should go to surgery for Children on time. So another question was uh the dilemma whether Children really feel pain. Uh Just like if I ask somebody. Now, do you remember the day you were circumcised. You may not remem remember because he, uh, and then we assume that the child did not feel the pain. But we, we all know that Children, even a day old child feels the same amount of pain that we feel as adults. It's just that they don't remember and um, they cannot register the pain and I don't know what it is. So every child feels pain and we should know that. So the short term cost of minimum of his surgery was um significantly different from open surgery. So this also because pedia surgeons deal with the this uh secondary payer, which is the child. So um we tend to see have more um empathy towards the child and more or less. Uh most, most parents parents are either unwilling or do not have enough resources to pay for this procedure, especially in the third world countries. I've met parents who um say, oh, I have six Children at home and I'm going to spend this much just for this uh baby's surgery when I have uh other five. So um they would prefer it to be done the other way around. So we also have challenges with instruments. Um This is a perfect example. I I'm sure almost all p surgeons have seen this picture before. So uh uh minimally invasive surgery instruments are so humongous and um cannot really fit for this baby. So, but as time went on and we um developed spinal and smaller instruments. It became possible to, um, do some complex procedures for these babies, the cavity, uh, um, that we need to do this surgery is way much more smaller in Children than in adults. Imagine doing a, um, a, a THSC repair for Sage Atresia in a one day old or two day old child, or even a week old child, sometimes pre time baby. Um, the size of the chest cavity that you are walking on is no bigger than uh uh uh uh the palm of your hand or a ma disc. Uh a much a much more so, um that is quite small and sometimes you have to really have a um ample dexterity and uh fine movements to be able to achieve this procedure. So, um for many pediatric surgeons, they feel it is too difficult or the procedure will take too long. And um such as that they will not want to even attempt or even a desire to learn such procedures. And sometimes we pride ourselves that, oh, we already use small incisions to do some surgeries like uh you know, uh we use very small incisions going in and repair the puss of a baby. So, um why do we need minimally invasive? People argue what is the benefit? And sometimes I had very difficult time to convince someone that um laparoscopic repair of inguinal hernia is very good. Uh Why they say, oh, I can do it with a to size, uh you know, incision. So um in infancy also on the is it really necessary in our third region? Uh because in Children is still the this procedure are still very young and we are still developing the procedure. So, uh most surgeons are very slow in picking up this um accepting this procedure to be done on their patients. And and this is the same narrative, almost the entire West Africa, we have very quiet, you know, volume of patients undergoing minimal invasive surgery. So um for any young pediatric surgeon to learn invasive surgery, the I think the first thing going through my own experience is that we must have mentors. So, and uh these are my mentors. Um and some of them were not really professors of minimal invasive surgery. They were just those that said, oh, I believe you can do it, just go ahead and do it. Uh And these ones are the ones that, you know, had very strong pillars in my life and helped me to, you know, um grow in this procedures. Um as a resident doctor, you only do surgery that you are allowed to do. So I uh when I said, I want to do laparoscopic Opex, uh my um my attending surgeon said, oh, are you sure you can do it? Ok. I will stand behind you and I will watch if you make any mistake, I will stop and I'll convert it to open. I said, no problem. So these are the people that you need to encourage you and tell you to go ahead and uh and they will stand behind you. So, yeah, you can um you can really achieve what you need to achieve. Then we also need to look up to those who have, you know, done the uh most difficult procedures like Professor Patoski and Professor Steven Rotenberg, who have done um very complex procedures in Children. And when you see them, you believe that this can be done and she you can easily, you know, uh desire to get to that stage. So second part is training and training and training. There is no end to training um uh or a creation of a dry labs and wet labs is the key to doing any um new surgical procedure or um it, it even more especially minimally invasive procedures to recreate the environment of, of those pathologies in the dry lab. And the wet lab is key to be able to, to uh to be able to carry out these procedures uh without problems. In um my center, we started um earlier where I did my residency, there was no instruments. So we had to start small. Um We had this uh patho sco I don't know if you can see my pointer. So that was our initial monitor and that was uh ii don't know this um inoculator that we used. And uh we had very, very weird instruments which I don't even know their names and their and their companies. So we were able to do diagnostic laparoscopies with this. And uh when my uh my, my professor went to the US, he was gifted this um this uh in circulator. So he came back, we were really happy we upgraded to this in circulator. And then we later uh went and bought um some metals and welded it together to create a, a tower. And that was our first tower. So the next one is this, this is um a gift that was given to us um uh that we had a, a full stack a again with the old monitor and a very, very old um tower with this, we carried out uh more than 100 procedures which are published in our um local journal. Uh and we later bought uh a flat screen television, yeah, or to make you create a monitor. So, um at emcare, this is our um our laparoscopic uh theater where we carry out a laparoscopy, this is totally out. So, what I'm trying to say is that you mustn't have everything you can start with what you have. You don't need to have all the hand game monitors and all the um beautiful uh equipment and scenarios before you can do um basic laparoscopic surgeries, you can always start with what you have and as you grow in it, you will get what you need. So which conjuncta normalities can be applied to minimally invasive surgery. Obviously, the anomalies are, are located in the body cavities, especially the abdomen and the chest. So these are the, uh these are the ones that we can um operate laparoscopically. And uh most procedures, most of these uh pathologies have been treated laparoscopically with success. And uh though we are still reviewing some of these procedures that uh some believe that laparoscopy may not be needed. So things like biliary rays. Um So I uh believe that believe that open procedure is still better than laparoscopic surgery. So in these situations, um this this uh pathologist may not be the best to go and uh um treat laparoscopically. But apart from that most other procedures, once the surgeon is um efficient enough, um it can be successfully done laparoscopically or thoracoscopically with. So I just want to show you just a few short videos of some of the procedures. This is make diverticulectomy. Um some of these patients presented only with bleeding, uh uh blood in stool and, and um I ii it, there may not be any physical evidence of the pathology until a me scan is done. So once the bowel is drawn, you can easily see the, the, the the maker of articulone. And this is a very easy procedure to do. It's like doing an appendectomy and uh it just is um separates the maker of articulo and ligate it in an endoloop uh also, and these Endoloops can easily be created. Even if you don't have your own endoloop, you can do a sliding not to um like get these um maker diverticulum and excise them. And most times the result is very, very uh fantastic. So, uh for digital Atresia is a, a more uh complex uh procedure uh because you have to do an anastomosis. Now, I uh at this time because of the, the size of the baby, um uh general surgeons are, are very happy because they have a big uh intestinal staplers that they can use to easily staple the bowel. Uh in pediatrics, our staplers are not so common, uh not so much available and those that are available are extremely expensive. Uh So we are forced to do intracorporeal anastomosis or at best, you can exteriorize the bowel and do extracorporeal anastomosis. So to, but in these babies to do intracorporeal anastomosis, you have to um align the bowel properly and have found the use of a he he stitches to be uh one of the best ways to do this just following the same principles of um de Atras. You must um check the distal bowel to be sure uh that there are patients before you commence anastomosis. And uh uh and this is the anastomosis for this patient. I did a diamond uh anastomosis that the one we usually do for resia. The benefit is uh is much wider and uh it doesn't easily collapse on itself. So I it's uh becomes more potent and reduces the time of um uh postoperative areas. So, with the hitch stitch in place, it is easy for the um area of anastomosis to be present before you. And you don't need to be uh looking for um the intestine moving around the abdominal cavity all the time. You wanna put a stitch. So you just um align it there and then you continue to do your uh anastomosis. Um You can do it with uh any technique, either running stitches or interrupt the stitches and it's all uh the same thing. So, uh, so the next one is heart disease. Um Of course, we know that of course, you know that uh uh uh in, in Hasbro's disease most, uh the, the, the bowel is, uh, it, it, it can dissect it from inside. That's usually the, the best way because here it, it's easy for you to take a biopsy and send for frozen section. And uh, w why you are still doing the surgery? And one advantage of doing this lab laparoscopically is that you spend less time retracting the anus and doing a primary trans anal put through. And the longer you stay in the anus, the more the chances of this patient having a permanent fecal incontinence, uh because uh the uh this can traumatize the, um the sphincters and can lead to incontinence. So, but when you have done almost all the dissections intracorporeally, it's easy to just pull it through the uh the, the anus and do your anastomosis without causing significant injury to the uh um to the sphincter, always have this in at the back of your mind. A patient with hash disease is not born with incontinence. So, if the patient has incontinence, it is a technical error. So to avoid this is um usually easier to do the abdominal approach first and then come down to do the um uh the, the uh the, the, the, the transanal. Ok. So the MS one, this tic her um thematic hernias. Uh I, is it the, what I discovered for this procedure is the ease of reducing the hernia. And the um II, the, the need to create a pneumothorax to be able to uh uh d uh to be able to create a walking space because the lungs at that side is a bit hypoplastic. So I don't need to in circulate a lot and I don't need a single lung ventilation for this baby. And you, most of these babies will come also with one or two congenital heart disease, which is mo most commonly asd or most also PD. But that in itself does not contraindicate the um primary repair of this uh asthmatic hernia. And I always use uh um nonabsorbable sutures to uh repair uh the the hernia. In these patients, there was no muscle at the lateral lateral wall. So we had to suture the um diaphragm to the rib cage um to complete the repair. So, for uh pyeloplasty, uh I II, it is um is one of the procedures that you really need to do a fine suture in because the whole repair depends on the ability to do accurate, you know, placement of sutures. So, um ii, it is for, to do this procedure. You, you should spend a lot of time uh in the, in the dry lab doing a lot of um suturing, suturing a lot of um uh uh uh small uh uh tissues and all that to be able to uh master fine uh suturing because the drainage of the, of the pelvis depends on um how well the anastomosis was done um for these patients. So, uh according to age atresia, uh this, this child uh was a 1.6 kg baby that uh was born at 35 weeks. So the issue here is um sometimes these uh patients, they, they can present in different ways. Um II, I'd like you to see the position of the patient. Um This, if you look at this, this, I usually place the patient almost in complete prone position just a little bit elevated on the right side. And this gives me um the ability to retract your lungs with completely with uh with gravity. And um using small amount of CO2 at a very low flow rate will also compress the lungs and expose the anatomical landmark. So, um this patient uh presented at uh at this age. And uh once you introduce your pulse, you'll be able to see the Azygos vein, which is the landmark for the procedure and then mobilize the esophagus below the Azygos vein. That's the distal esophagus below Azygos vein. And then I always use a hitch stitch. Also, you can notice that in almost all my procedures, you will see hitch stitch, hitch stitch. This helps me to align the atomy properly. And that's the best way to um like get this um esophagus at the entrance in the trachea. So this is the upper pouch. For me. The most critical part of this procedure is the mobilization of the upper pouch because this is the time you can easily inadvertently enter into the membranous trachea. And once you are in the immunal trachea, your anesthetist will become a um and the C two will go up and you may likely convert to open. So that is the time you have to be extra careful to uh IMIL the esophagus properly without injuring the trachea. So once the opals is commenced, um usually I leave the azygos vein intact. There are several, you know, arguments as to whether to leave it intact or to uh like get it, but whichever one is more convenient for you um is, is OK uh as they get the same results. So like every other principle, the posterior wall is usually the first uh in these patients, the, the esophagus was a bit wide apart. So it was almost more than two vertebrae apart. So it was quite uh um under some degree of tension. So we have to use the sliding knot technique to bring the two edges together. You, you, you, you can see it was quite under some degree of tension and uh we had to bring them together gradually and that is the tube going down. So some of them can come in a very nice manner. You know, the um the two ends are not too wide apart and then osmosis is so easy. And um there is one con condition I've usually uh I've seen is supposed to be easier, but sometimes the esophagus, the distal esophagus is fused with the proximal esophagus and there is no communication between the two. It's like there is a fusion. So in that situation, it's easy for you to inadvertently um enter into the trachea because you are looking for the upper pouch in that situation. So this baby, even though he had a very long, you know, uh uh quite some uh quite a long gap, we were able to come anastomosis and um she healed quite well and uh was able to be discharged home. So for lobectomies, I place the patient on the lateral position, the um surgeons are standing at the front of the patient and the monitor at the back of the patients. Um II, it's important to align the uh ports so that you can easily visualize the um sorry. So you can easily visualize the the fissures of the lungs because uh that is why you want to do the um surgery through is the fissures of the lungs. So the first thing that meets your eye is the, is the cyst. This patient had had multiple um large cysts in the lungs. So first thing I do is to collapse the cysts with the energy device. So once you collapse the cyst, you easily have walking space for them. And then starting with the pulmonary arteries, you clip the arteries and then um ligate and divide. Some people use ligation only to clip the to, to uh burn the pulmonary arteries. Um But me being too cautious and uh maybe um not really so trustworthy of ligation, I prefer to apply my two clips and um divide with ligation. Then one should not miss the lingula lingula vessel, which is usually at the edge. So sometimes it can be quite troublesome. So after the pulmonary arteries have been ligated, the lungs can be flipped over to see the pulmonary veins which is just a bit uh behind. And um those will also be ligated equally in the same manner. So, um one of the mistakes that can be done in this procedure is inadvertently like getting the vessels or the bronchi that are supplying the lungs tissue that you do not want to remove. So because of this, you stay as close as possible to the diseased lung um to avoid, you know, um ii inhibited injury to the normal to the healthy lungs. So, um after the pulmonary veins have been um divided, they will gonna focus on the, on the uh segmental bronchi. Um which of course, you can see they are quite different and a bit thicker and um I always like get them with tan clips before, you know, dividing. Yeah, for the left lobectomy, you, you should be ready to also encounter lingual uh branches, um which also will be in the way before you divide them. This child was six months old when we did her um surgery and the, the we made a diagnosis when she was still prenatally, uh prenatal when she was still in the womb. And um we made it did the surgery at the age of um six months and she did quite well. And uh um she's two years old now and she is doing well. So this child had posterior valve and um after, after um ablation, we still realized that he had um reflux on the left side. So, uh you had to do ureter implantation. So it is one of the most difficult surgeries I've ever done uh for this kind of patients. So one of you can see a very big megaureter in this boy. And um you, once he's mobilized, you have to divide it flush to the bladder. But one thing one has to take care of is the vas difference. The vast difference is just above the part, the site where the um ureter enters into the bladder. So one has to be very careful to avoid uh injury or like or in inadvertent ligation of the vas difference. So you can see the vas difference just running on top here of the um of the urethra. So for me, I usually exteriorize the uh the ureter, the megaureter and uh trim it before co uh continuing with reimplantation. So just ize it through a small five site and then um trim it over a catheter before um reimplant in the ureter. So, so to re implant the ureter first, the bladder is filled with um saline and then we start to create the tunnel. So the this is where one has to be careful not to enter into the mucosa of the bladder and then per anastomosis. So you see the mucosa bulging out and um where the tunnel is being created. So, um after this, we'll now close the tunnel over the uh ureter. So this tunnel has to be at least two times this um width of the ureter itself to be able to create that valve, um that valve effect um for the ureter. So, um there are new techniques of doing this, which is a Vesico uh technique um that can also be done for these patients. So, this child did extremely well, the uh ureter, you know, were emptying better and the um kidney function significantly improved. So, um what are our outcomes? Um excellent outcomes uh currently, according to um regular standards, and you see these babies have, you know, um minimal scarring and uh the the uh the effect of thoracotomies um in on, on these patients is completely eliminated by using minimally invasive uh technique. And um if patient that had la la laparoscopy, you barely can see the um scars, this child had Gegen Atras and was repaired laparoscopically. And um I'm sure you barely see the wound sites. And this is the child that had um thoracoscopic for aia. So what are our challenges? Um Single lung ventilation is almost impossible in units. And um because of that, um uh we just use lung compression with CO2 and um sometimes people have tried bronchial blockers, but it's extremely difficult. It requires a lot of expertise and spends a lot of time in uh in, in this day. So we just go ahead with um single lung uh sorry, with um with compression with CO2. And that has worked quite well even with patients that have um all anomalies. Um use gravity to your advantage to retract the uh the the lungs away, use it to retract the bowel away or any other structure in this patient. And then each stitch, he ST he stitch uh is very good for babies, especially when we don't have the luxury of putting in fine retractors uh like in adults and all those and using a staplers like in adults, then we need proper instru instrumentation. Three millimeter instruments is very important in um managing um infants and babies doing surgery for them. So, uh there is almost no pediatric presentation that does not um say Children are not small adults, they are not. So um the P is different and we must respect that and um manage it appropriately. Ation pressure for these patients is not the same with that of adults. Um For thoracoscopy, I don't go beyond six M, the mercury for la la laparoscopies, I don't go beyond 10, the mercury because of their effects on the, on the uh on the patient. So you can start small um less complex cases, diagnostic procedures, um uh procedures like orchidopexy appendectomies. These are important procedures that can, that will not take a lot of time. So um these are our testimonies, uh babies that had uh good success and this child was the one that had a longer pares. Um she recovered quite well and the mother allowed us to put this picture. Yeah. So we uh one important thing that helped us to succeed is smooth collaboration with neurologist and pediatricians and in managing these patients postoperatively, no matter how you do the surgery, whether open or closed, you must manage these patients with your pediatrician colleagues and your nematology colleagues. That's the only thing that guarantees postoperative survival and advanced laparoscopic surgery is still growing and we need uh more training and skill acquisition teamwork cannot be overemphasized. Thank you so much. Uh Th Thank you AUA. That was really excellent talk and, and your videos speak for themselves. So I'm very happy and very proud of what you have achieved in Africa. Um I've got lots of uh senior colleagues who are joining from various uh parts of the world and we have about 75 colleagues attending, which is quite remarkable. So I see doctor Be Nandi who is a good friend of mine and who who works in Malawi is here bip your comments, your experience in Malawi, it looks like Doctor Nandi has gone offline. So the next uh professor I would like to ask the Professor Romao from Dar is here. Uh Roma, can you uh give your your uh comments? It looks like she's also offline. Um I saw Professor Bertin was here. He he still, no, he's also left. Uh I see doctor Soto has already commented. Doctor Soto is joining uh from Dominican Republic. Doctor Soto. Uh anything you would like to say, please unmute yourself and and say it uh first uh grading from Dominican Republic to all of you, uh congratulated professor and I agree. Uh One of the most important thing to, to achieve AAA good experience in the minimal invasive surgery is to perform and perfection at our skill, we must uh train and also have a mentor in the beginning. Uh It's very useful to have a mentor who can uh be with us uh getting more experience and and in having the moving to other pathology. So uh that the things that can guarantee us the, the preparation and the exit of our procedure. Thank you very much. Th thank you doctor. So uh very, very valid comments of, of acquiring the skills, having mentors and uh only doing what you have been trained to do. Uh There is a commented question uh from, from Doctor Chris. Uh uh So Arua uh Doctor Chris is asking what is your mortality rate for esophageal atresia? Uh thoracoscopic versus open surgery? Oh OK. Can you hear me? Yes, yes, you can uh answer that. Yeah. Yeah. Yeah. Yeah. Thank you. Uh doctor. Um Yeah. So, oh, so since we started um thoracoscopic repair um and also I am attributing this to excellent care by the neato uh we've not lost any patients. We've had 100% mortality though our number of cases is just about uh 10. So um since I started doing this procedure, um but I've lost um a lot of cases um while I was doing open procedures, um most not because of the surgery itself but because of the postoperative care uh of these patients. So, um the most important part of this, of patient Survivor for me is postoperative care because some of these patients, even those that we did thoracoscopy, um We nearly lost some of them. Um They were on, some of them were on mechanical ventilation for up to a week, sometimes more than a week. Um So the real reason for their survival is not the dexterity of the surgeon, but the collaborative handwork between the surgeon and the neurologists. So, um thank you. I don't know if I answered that well. Uh No, I think that that was uh well answered. Uh I think uh another important aspect which you covered in your talk and also emphasized now, teamwork is absolutely essential, not only inside the operation room, but also during the pre and postoperative management of the patient. Uh I see there is one more question from Doctor Mohammed. How do you manage bronchopleural fistula after lobectomy? And what age do you do? OK. For um for lobectomy, uh one, the first thing is to avoid bronchopleural fistula. Uh It's a very, it's a very difficult thing to manage and depending on the size of the leak, you may have to go back in to close the fistula. Yes. And so, um but uh II have not had an experience of bronchopulmonary fistula following thoracoscopic lobectomy. Um But the, the last one I saw was um when I was in Carac units um during my residency rotation. Um after open lobectomy um had a bronchopleural fistula, we had to go back to close the fistula. So depending on the size of the fistula. Uh Sometimes it uh it may close very small once, depending on how severe it is. But most times if it's a big leak, patients having recurrent pneumothorax, you may have to go and close it. Ok, thank you. Um I have two more colleagues uh from our department uh to ask uh for the comments. But uh can I ask you some general questions? So comparing the time for operation and the cost uh II know you're working in the private hospital. So cost uh uh do you spend longer time in theater, skin to skin? And is the cost for the parents much higher? Ok. Um For me, I believe the cost is, is lower because the time um I spend in the theater, the first case I did, I spent three hours in the theater subsequently. I've not spent more than two hours doing the surgery itself from skin to skin and sometimes about one hour or uh one hour doing the whole surgery. So, but the our first case was up to three hours. So um um mostly because intraoperatively um your your nurses, I'm not so aware of what you are doing. So you have to keep giving instructions. Get me this, get me that um which you know, um take some time and uh and those are the things that really take time. But the procedure itself, if it goes well, usually lasts within an hour or one hour, 30 minutes. So, um uh but the cost itself in, in our hospital, I don't think it's cost more to do it tropically rather after doing it open. Um, the, the patient stays longer in the hospital and spends more time in the ICU. So because of that, you have to spend more. That's what I think. That's my own way of thinking about it if I, but it's been a long time I did open. So uh uh uh to do the comparison now is quite difficult. OK. And uh my uh uh there is uh another uh nice question. But before that whatever cases you have done, are you happy with their postoperative complications? Are they comparable to uh your or your colleagues results for open surgery? Uh OK. So um most of the uh cases I've done um the possibility complications are quite minimal. Um The ones I've uh seen and then there was the ones uh that really went out of line. Um was one case of um uh uh esophageal esophageal um uh corrosive corgis. Yes. So we did a laparoscopic mobilization and then uh a trans put you pull up. So the patient had AAA quite terrible leak which um uh was quite difficult for us to manage the, the patient patients pulled through and was able, able to discharge him home. So that was the my most difficult um complication that had doing uh these procedures. But basically um things like esophageal atresia, uh, atresias hash disease. Uh, ok. One hash disease had a leak, anastomotic leak which caused peritonitis and we had to go back and place a colostomy. That was one patient. And, um, those are, those are the ones that, um, really gave us significant trouble. Yeah. But apart from that, that, um, good, um, outcomes. Ok. There is, uh, a question from Doctor Leonard. Um, have you met with a big case of esophageal atresia? That was I think what Doctor Leonard means is uh have you um uh encountered a long gap esophageal atresia? And what did you do? I think you spoke about it, but I think he wants to know what operation did you do and then what are postoperative precautions you take? OK. So um lung gap has so many definitions um in the textbook definition, which is about when it's more than two vertebrae apart um can occur in type C. So I had a type Co Atras which was more than two vertebrae apart. The, the one that's usually uh some people call a trifurcated fistula where the fistula is located at the carina. So because of that, um that was the one I showed in the video and um the use of sliding knots is very, very good for these kind of cases. You can easily, you know, bring the two edges together when you use sliding knots. But before you do that, mobilization of the upper pouch has to be, you know, as high up as into the neck, as much as possible, that's um will help you gain more l and um easily reduce the tension. Then in sometimes you may want to do mobilization of the, of the, of the lower um esophageal esophagus. But uh this is not very encouraged because of the um 10 blood supply of this um of this part of the GST. Then um I also met a type A um that's, that's a lung gap without any fistula. So that's one. I tried to do the Patoski technique which is the um uh uh the intracorporeal um uh traction sutures. So, but the baby was quite frail and uh the the sutures were cutting through. So I just put it's a vag and a gastrostomy for the patient. So the patient uh um uh discharged without complications. Excellent. Thank you. Um Professor Bet Cow Bein CME, can you hear me uh if you have any comments, please unmute yourself, Professor Bein. OK. If not, then I will ask uh Doctor Sello Mataya who is one of our senior consultant, pediatric surgeon and significant laparoscopic skills to give his comments. Seller. Hi, thanks. Uh Thanks for the talk. Uh Very informative and good to hear that we trying to do. First of all things in this little corner of Africa that we live in. The one thing I was glad to hear is that um you actually using multidisciplinary and utilizing the neonatologist, if you have in your facility to actually help optimize because that's the issue we sometimes have in our facilities where it's not the surgeons who can't operate. It's the care postoperatively which hinders us to do more um, interesting operations if I can say that. But the one thing I wanted to find out, um is how do you um select your patients, do you just say? Ok, this patient has this condition. Um I don't necessarily care about the other associated chromosomal anomalies, et cetera. Um I'll just go ahead and do it laparoscopically or thoracoscopically or do you have patients which you from the get go say that I will not even attempt to do this thing minimally invasive. I'll just go ahead and do it open. Yes. Um Absolutely. Uh I have patients that I don't even need to attempt a minimally invasive procedure. Um And one of my cues uh to avoid that is when you have a hemodynamically significant congenital and congenital heart disease. Uh That is my um most, you know, important um contraindication. Um As long as the congenital anomaly is hemodynamically significant. I will avoid anything that involves in circulation of CO2 involve long um uh uh uh uh long, long procedures and all that. Um However, some patients that have a small PDA, a small asd um no hemodynamics, um uh uh um significantly challenging hemodynamic condition is not requiring significant Atro so we've done um thoracoscopy for those patients. Uh We've done a laparoscopy also, sometimes if the patient is too small. Um uh uh we may, we may need to wait for some time place on the top and push for the patient to gain some weight. Uh, if necessary place a gastrostomy for the patient and uh, wait for the patient to gain some weight before we go ahead with the surgery. Ok, thank you. Um, Sarah, anything else? No, that's all. Thanks Bob. Thanks for the talk again. Ok, thank you. Um um I think Professor Burton uh is able to uh um comment. Professor Burton, you can just uh unmute yourself and, and make your comment. Uh Thank you for the invitation for this um laparoscopy. Do you, do you understand me? Yes, yes, please go ahead. Ok. Ok, please II have some problem with my connection uh uh a few minutes ago. So I've, I've changed to the phone. Uh Let me tell to ask you to uh uh what about the time, a long time to have a training to, to be able to perform uh congenital laparoscopic because II do have a training in France, but because we have no training in hospital in Cote d'ivoire, we have many problem to have uh a competence to be efficient in laparoscopy. So I see in this, the training, the training uh with uh senior training. And the question is how long the train the, the training is uh is important to have to be able to make a laparoscopic in Children in the, in the congenital abnormality. Thank. Thank you for the question. Uh Arua, you can answer Professor Burton's question. Ok, sir. Um How long um for, for me, uh uh uh I think most of the training once in about training is some surgeons think or, or feel that um they, they must have one beautifully organized training, training session for them to get proficiency. But the fact is that proficiency is not gotten in the, in the beautifully organized training sessions. It's a, it's usually a short term and um most of the training is a person. It's a, it's personal, it's a personal training. So you, you go, you go to those um beautifully organized training sessions to get clues on what to do on and how to do it. Then when you come back, you spend unlimited amount of time training yourself. So, uh most of the things I was able to do was the things I was able to simulate myself in my own dry lab and spend several weeks, several times training and suturing and um making the mistakes and learning how to overcome those mistakes on my own. So even though I went for the training, but II still have to go back, take the um uh dry labs and practice and practice and practice. In fact, um some of my colleagues called me the video game doctor. Uh I II take the lab with me, um, in my car everywhere. And anytime I have a AAA space, I just set up the, um, model. I start training. And before I did my first resia, I did more than 100 anastomosis. And until I believe they were perfect, I did not attempt any procedure. So, um, I think most of the things that if I, if we identify the doctor that is, uh, interested in minimal surgery, the support that the person needs to get is just to have his own training model. Once he has his own training model, it is his responsibility to continue to do the training and um, do it as often as possible. And, uh, uh, that's the only way to get proficiency. That is my, I think, I think it was an excellent question and you have answered it very well. I think these hours spent in, in the skills lab or, or your simulator dry lab are absolute must before you attempt, uh, any minimally invasive procedure on such a small baby. Um, I have, uh, one question for you. Um, uh, uh, which is, which is, uh, do you, do you have, um, laparoscopic trainer? Yes, I do. Is it, is it something which you have devised? Because it's a pity that doctor or Mr Hans man who is a senior pediatric surgeon in Ter Marburg in South Africa is unable to attend because he and his unit have developed, uh, a very low resource, uh compliant laparoscopic training model with just use of domestic appliances. So, do you have a trainer or you have devised a trainer of your own? So, yes, I um, my first trainer was uh a box made of cotton and uh a webcam and uh with uh uh foams and uh uh uh uh plastic tubes that I used to do the training. So, of course, uh what, what we, what I used then was locally, you know, devices. And uh um later we were gifted um from COVID and one of the, the old training boxes, which I also use several times. And uh those are the things I use. Then when I go to uh one of my mentors um gifted me a training box, a new brand new training box. So, so everything was um training box training box. Then II created series of training boxes with um with a carpenter. So we built it with uh with wood and put a webcam inside it. So I think it's just a high definition webcam and uh a box to simulate the cavity. Yeah. Thank you. Uh Before I take final comments, one question uh to you is do you believe that uh uh trainee pediatric surgeon needs to master open technique of any particular operation before trying a minimally invasive technique like should register do at least one or two pils before attempting laparoscopic um in my environment. Yes. In, in the third world countries where you, you don't have everything. Yes, you should. It is a must that you should know, um, the open technique, you should have done some of the open technique before you go. Um, and, um, start doing, um, laparoscopy for those, for those procedures. A and also when we continue to grow in the third world country and we get to a particular level, it, it becomes, you know, um, easy just to transition, you know, in, in, in certain places. Um Cholecystectomy is only done laparoscopically, irrespective of the type of gallbladder. A appendectomies are only done laparoscopically. So, um sometimes your first time of being appendix will be laparoscopic. So, uh and um so ii, it will come to that point at a time when pediatric surgeons will be your first um uh p myotomy will be laparoscopic. But for now in our environment, it may not be feasible. So it's important for us to start with open. Yeah. Um I think, I think you're absolutely right. I remember I uh doctor of Professor Klaus Bax, uh a very senior and pioneer pediatric laparoscopic and minimally invasive surgeon from Netherlands was one of the faculty for a laparoscopic uh training course which I was fortunate to attend in Aberdeen in Scotland. And in those days, in 2006, he said that 80% of surgeries done in Children in his unit were done by minimally invasive techniques. So they, they are far advanced, but I think unless we start somewhere, uh we will go nowhere and you are absolutely right. I think um uh new generation of trainees will come where they have only seen laparoscopic Pym myotomy. They have only seen appendix removed by laparoscopic procedures. So II think we, we are on the right path. The final senior person I ask comment is doctor Yashoda man who is a senior consultant, pediatric surgeon, quite skilled in laparoscopic work. So Yashoda your comments. Uh Thanks prof uh thank you doctor I. That was uh really an inspirational talk for us. And um it was great coming from a fellow African. So um it's very impressive and commendable what you're doing there in Nigeria and it just shows what passion and enthusiasm can do. And in your case, I hope you have trainees uh because I think you need the opportunity to be a mentor to others and to pass that on. So I hope you do have trainees and thank you for the little tips like the hitch um stitch which I will try to use. And I think your, the the challenges that you spoke about is uh exactly the challenges we have here um Along with budgetary cons uh constraints which I think we might be suffering a bit more here. Um But uh like three millimeter, five millimeter um harmonics and uh clip appliers is a bit difficult to get. So, um but we are trying as much as possible and you've inspired us to do more. So, thank you, thank you so much. And I, I'm really happy to hear what you are saying and, um, I started the same way and we had almost next to nothing. And, uh, of course, you saw those pictures of my old uh tower and uh, those are how it started. And when I saw for the very first time it was looking like Mr dispense for me, I used Hook for everything. So, um I don't think I II think this time is a time of um that we can't forget uh those good old days of who is, who is in hook for everything. II didn't even have a bipolar, a bipolar. So, um you can imagine what that means. So, thank you so much for your comments and um don't give up, I believe um once before you know it, you will see what you need and you will grab it. Sure. Thank you so much. Thank you. Thank you Arua. Um Just a couple of more things uh is, is uh uh uh I just want to uh sort of inform announce that uh the next year pan-african Pediatric Surgical Association conference will be held in Abidjan Coar um uh from the 27th to the 29th of May 2025. And uh the local organizing committee is planning to have a preconference laparoscopic skills workshop. And if that happens, we are going to invite uh doctor wide to be one of the faculty uh the next month that is month of March, we will have an interesting talk on clinical exstrophy, African perspective by Doctor Marian Arnold who is a consultant pediatric surgeon and with special interest in pediatric colorectal surgery. Um So the invitation will be circulated a week before the meeting. Um The recording of this meeting will be available on youtube bit later today. So aa uh just before we depart your final concluding uh remark or take home message, please. Uh Yeah, thank you. Uh My message will be to um other young surgeons like me and uh every other person in Africa and third world country is in the same um situation. Um So it all, all it takes is determination and um perseverance and willingness to overcome all the odds that are facing you. Um It may be difficult sometimes but, you know, with great enthusiasm, you will usually find what you need, you know. Uh II just uh I just saw, you know, some, some, some people that were willing to help me to get what I need for me to practice what I know how to do. And once I got those things, you know, every pediatric surgeon, once you get the right tools you fly. So that's what I want to say. Thank you. Thank you very much. Thank you, everybody. I really appreciate your participation and uh we hope to see you next month. AA I hope to meet you in person in Abidjan. So thank you again and, and uh we'll see you next month. Bye-bye. Goodbye.