Computer generated transcript

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

Uh uh. Okay. Good evening, everybody. My name is, uh, Mr Raja Lingam. I'm a, uh, post CCT fellow in colorectal surgery. Um, currently, the Children are still doing some, um, general surgery of childhood and general pediatric surgery about my interests are entirely correct. All. And today I'm going to talk to you about, uh, colorectal rectal resections. And we're focusing on on the laproscopic aspect of it going through, um, the anatomy, the setup, the approach and procedure, um, pitfalls as well as, um has a tips and tricks. Um, I'm aware there is a varied audience, uh, to this, uh, to this seminar. Um, so hopefully this thing there for everybody apologize if, uh, some of the aspects of, uh, the presentation of the talk is, uh, perhaps a little basic for you, but this is to make sure that we capture as much, uh, helps much other colleagues as possible. All right. Okay. So moving on why we do correct receptions? Um, uh, Generally speak the vast majority. Call directoral receptions. Bind options as well. Uh, suggest that particular disease. Many patient's with bowel cancer have, uh, bowel resection surgery as part of the treatment and knowing the anatomy as well as the set up for the procedures. Uh, crucial. So that was safe and effective surgery, especially cancer surgery. So the limit your test today? I don't understand. And apply the anatomy of the GI tract and, uh, understanding the principal. All right. Neglect me having an enhancements procedure. I said that these two operations because they have, you know, they sort of give you a good good idea what correct rejections generally like as well as and the different techniques we employ. But also giving thing an an idea of some of the strategies dealing trains, as opposed to rights are resections. But, you know, you could substitute harmless procedure with a high interior. So and you know, the vast majority of the steps will be the same. Uh, and for, uh, the those a bit more advanced among you. Um, you know, having an awareness of the technique indications as well as tips and tricks and having an idea of the complications. So a right hemicolectomy and starting very basic here is essentially it's a bit of what we do is a bit of plumbing. As you can see, the this is a diagram of the colon. And, uh, we've got here tumor close to the hepatic flexure. And we need to resect this tumor as in keeping with oncological principles. We need to make sure that we the blood supply, which contains the lymph node, uh, which is key to, uh, to make sure that we have a leader section but also reduce the risk of recurrence. Uh, we will remove the entire, uh, right colon as well as part of the transverse colon. Now, Rome o'clock, usually for cancer. Uh, has other indications as well. Um uh, you know, for example, as we alluded to earlier, uh, inflammatory bowel disease. Or they could be of Aldous, Uh, even polyp disease, especially, uh, there are too big to be taken out by by advancing this copy techniques. For example, polyps that, uh, large polyps at the base of the cecum, or or including the appendix, and typically, this will result in ileo colic anastomosis, which is, uh, estamos between the Eileen and the colon. Hence the name. Right? So the principles are writing the colectomy is to make sure we remove the cancer. So I'm I'm assuming that we're gonna talk about a cancer operation here, and this is for spasticity. Uh, we're gonna remove the cancer. We want a good margin of normal colon. Uh, we want to preserve session envelopes. We don't want to get into places we don't have to go to and potentially seed problems. Um, and we don't want. And we want to get a high ligation of the vascular pedicle. And this is, you know, due to the fact that a little earlier is to get the lymph nodes, which can contain, uh, metastatic deposits and reduce the risk of, uh, local or distant recurrence. Okay, so the setup and again, we're going to talk about laproscopic operations here. The open operation. Essentially, it's the same in terms of principles, but has got some key differences. Obviously, the main advantage of laproscopic surgery is that we can get away with the incision this big as opposed to one. That's a bike. Um, and the hesitations for pain as the higher you are, you go up, uh, in the abdomen. Um, uh, risk of the, you know, risk complications of pain much higher. Especially to, uh, and among other risks as well. So the setup would be typically a 12 millimeter port. Uh, here for your camera. Although you can get away with smaller ports, you'll still need a port. Uh, you'll still need a working port, uh, for your staplers, if you choose Staples. So typically, a 12 millimeter port here, uh, and then a, uh, either five or 12 on this side. And then the same, uh, five on on these two lower ports as well. So you're working right hand port. We'll probably have a 12 just so you can get a staples. But if you have a five millimeter camera, you can have a You know, there's no reason why you can't have that at five. And then you use this to file a stapler. Okay, so, uh, you know, you set up in this fashion and and here I've got a picture of the instruments here. Um, but typically, you you'll have the surgeon standing on the patient's left hand side, Uh, the camera stack on the patient's right hand side and very much as you set up for, uh, an appendix. Really? Um, for laproscopic appendix. You know, we're just doing a much bigger appendix. Um, so then we go for the procedure. So this is the view you want to get before you start doing any cutting. Okay, so here, at this point you've got your ports in. You've obviously got pneumoperitoneum. Uh, typically, this might be a 12 millimeters of mercury, Uh, CO2 of, uh and you've moved the small bowel. So you've mobilized a small bowel on on the route of history towards the left upper quadrant you've taken. There's a bit of momentum. You're taking the transverse colon and put it back up, ideally tucked under the liver. You've taken the right call on with your, uh, with a your retraction port here and lift it up right up to the to the, uh I don't know, wall so that you can identify the ileo colic. Vascular pedicle. Um, now, you don't always see a duodenum in parts of the world where people generally are a bit more generous along along the ways to have carrying off into abdominal fat. Uh, you know the duty, um, we buried under the mesentery. And, you know, you've not always get a beautiful picture, the during them straight up like this. Um, but if you see it well, and good, because that makes your life much, much easier. I should say there can be variations to this technique. Uh, so in this particular port placement, this is retraction these to the working ports, and this will be at 12. However, you can also, um, it this port, uh, you can make this a working port, this working port and a further retraction port up here, and that's perfectly acceptable. Uh, way to do it as well. Yeah, right. So here, now, we've identified the electronic vascular pedicle, and we want to try and get into the infra colic space, uh, so in from mesentery base. And that involves making incision with him very much as where the end of the scissors is, and you could use a pair of scissors with bipolar attached to it. However, it's quite common practice in the United Kingdom to use a energy device, and my preference is to use a harmonic energy device. However, you can use an air whatever you fancy. Uh, what do you have? And whatever you're trained, competent enough to do and and you'll have generally any trauma it grasper maybe a johan's or bio grasp on your left hand and you make incision on the peritoneal surface. And what you're trying to do here is to lift up the mesocolon, uh, and getting the space between the musical on and the underlying fascia. Um, and you want everything else that isn't the musical. Uh, and typically, you could make sure that, uh, the para nephric fat stays with the kidney and not a left hand. And the idea is so that you could expose the duodenum. See, shortly, um, you probably see there and two identity limits of our dissection. And from the bottom end, uh, you want to go as high as possible, uh, towards the corner, lend and typically you you know, you're heading for the liver. Uh, go as high as you can towards the liver because that all your life much easier when you come to do the second part of the operation and the same way laterally you want to get as much as far laterally enough so that you could generate a space between the colon and the abdominal wall. Uh, and that will make dividing the attachments of the colon the bronchial much, much easier. So when you finally identify the duodenum, which you can see here, and you then safe. You want to mobilize until you can see the sea of the duodenum And once you've got the sea duodenum, then you're high enough on the ileocolic pedicle and you can skeletonize the pedicle. As you can see, the pedicle with the with the electronic artery, and it's venous drainage has been skeletonized, usually with an energy device, uh, can see the structures very clearly from the surrounding fat. And the way you can deal with this, uh, the various ways you can deal with this. So in this particular example that we dealt with with, uh, Humalog, which is a clip applicator clip, uh, large clip application, However, you can also stable across this with with a vascular stapler. As you can see here, the the, uh, the hemlock has been applied and the structures been divided. And you can see here the duodenum has been kept safe, and it's very important that is, that the music alone is low away from the jury, um, as so that it's not injured during the application of the clip or the stapler and and the urine, um as you can see the sea of the durian, um is where you limit is, uh, and, uh, anything beyond it, uh, would risk damage to quite important structures. The the pancreas is here, and as you will come to shortly, the, uh, right colleague vein which can brain to the gastro proper epiploic vein, um, which can train into the super mesenteric vein, can be injured in this process. And that can lead to a lot of heartache for both for you and the patient. So this is the next stage of the procedure. Once you've divided this, you then have more mesocolon. And here you want to make sure that we get as much as high as possible. Now it's very, very common in patient's that are very thin for you to go through that you didn't intend to and such as this layer Here. You see, there's an all sign. So this is a layer that the surgeon didn't want to go through. Uh, because this is underneath the duodenum. But because the medicine tree has has windows that extremely thin, it's very easily done. No big problem if you do it. It's just as long as you recognize that that's happened. You get back in plain as the surgeon is done here so they can get the colon or lifted. And you want to go as high as you can and lateral as you can so that you get the color mobilized. And if you do that correctly, then the next stage of the procedure becomes much, much easier. So once you've mobilized intra chronically, then the next stage, if you've done well enough, be fairly straightforward because all these lines and then uh then visible to you so just to orient everybody. So now we're going on the transverse colon. So that's the transfers. Call on here is the transverse colon attachment. Uh, that's the liver gallbladder. And this is the thunder beat energy device, which is also another, uh, type of energy device. And here the surgeon has put the put the brought the call on down, had a look and found the bruise of his disease of his inferior dissection, made a cut and immediately joined up from the top the in fear dissection. So he will go around the corner to, uh, to free up the hepatic flexure and from the bottom, you know, holding onto the appendix, which is just here, or the cecum. Uh, you can lift up the right to call on in the cecum and then identify planes where you've detected previously and carry on the dissection. And your idea is to mobilize the entire, uh, uh, see of the colon or the right colon rather, uh, so that you can then mobilize it right up to the midline. So that's the key in in every colonic operation is the colon. Uh, off. I mean, the GI track starts off as a midlife an organ, and we're going to we're going to, uh, return it line. So by doing this, you return the colon on back to the midline. Um, and then you're ready to deliver the colon through, uh, once you've confirmed the mobility of where your dissection, uh, limits are. Then you're then ready to do the estima. See receptionist, um, ASUs, which particularly done via the umbilical incision. So going to the initial setup. As you can see, the line here is a bit longer. So initially, you may start off with a 12 m here, Uh uh And then you expect, uh, something a bit longer. And you can put a wound protector so we use the Alexis wound, protect the system, and that has the benefit of both retracting, uh, the wound ages, but also protecting the wound edges from the contamination. So deliver the a call on, uh, which you've now can be mobilized. And the idea is you want to resect the entire right colon. Estima is the two. So this particular style of anastomosis, uh, is called the Barcelona Technique and using a stapler, however, you don't have to use this technique. You can use a an end to end, uh, hand sewn anastomosis, and that's perfectly acceptable. Uh, this is one that I prefer it It's fairly quick to do, and and the staples are fairly, fairly safe. So this is what's, uh, making sure you've got the distal limb it. So you're not going to cut through cancer feeling for the cancer? If there was a tattoo, then you know you've identified where the tattoo is, uh and again, for those of you who aren't familiar with tattoos, uh, it's usually, uh, in the ink applied endoscopically. And it's important to note, uh, on the and oscopy form or the result which side of the lesion the tattoo was applied. Now, as as a department, and you should have a policy. And it's useful to the surgeon if the tattoos applied to the anal side e the site closer to the, uh, the lesion so that the surgeon interruptive li if he can't feel the tumor or the polyp can rely on the tattoo, which will show on the bowel to identify his reception limits. So he knows anything beyond the tattoo towards the anal side is safe. Uh, so moving on here, uh, once you've identified you where you want to resect, uh, and where you're going to an Eskimo. So you don't have to put the states, which is to begin with, you just have to get them together. Uh, identify. Make sure you're on the anti mesenteric border because you don't want to be firing a stapler through the mesentery, which will compromise in esteem. ASUs, um make the antrostomies, uh, and put the two ends of the stapler. And once you've confirmed that nothing else has been caught in between, you can fire the stapler and that creates this particular anastomosis here because obviously stapler fires to Rosa Staples and divides in between. Therefore, you have two walls joined together and a division between creating anastomosis. And then you want to reset and close your and talk to me at the same time with another fire at the Staples or the cross staple, uh, and then end up with this particular picture where the anastomosis you have the ileum and then the distal distal transverse call on going this way. Now, typically, this will result in a large dysenteric defect of the two ends of the mesentery. And a large mesentery defect is not generally a problem. Obviously, we have a rather small one. Then you would, you know, you would worry about other bits of small bowel going through the defect and not getting trapped and causing small bowel obstruction necessary, eating a return to theater or a approximate a future date. So if you have a small mesenteric defect, then it's, you know, you probably best close it. However, large genetic defect generally not a problem. So you know, just the pitfalls we talk about. And and it's just to identify, uh, like everything in surge, very important to be in the right place and especially in the laproscopic operation, where you are doing an inferior in in, you know, inferior mesenteric, Uh, infra mesenteric mobilization or infocomm bill ization. It's important to be in front, uh, superior to the and not behind it, because then you can run to trouble. Um, so your your your your first incision. As you go through, you go through the, um, right call on you. Want to make sure that you are in front of the duodenum and you're dropping the duodenum down and you're not going into other spaces. The deep separate little fascia don't want to go over the J Rotas or the kidney and mobilize the kidney along with it. And it's not a problem if you breach these, but it's important that you recognize that that's happened and you get back into plain because it's very important that you're on the right plane. It helps you stop mobilizing that you don't want to mobilize but also help stop unnecessary and unwanted bleeding, some of which, as alluded to earlier. If you, uh, potentially damage the gastrocolic trunk of Henley Um, which typically hands at the point when you deliver the colon. Uh, and the special your wound, uh, traction injury can can can result in the avulsion of the right colleague vein if there's one present or any other draining vein the gastrocolic towards the gastrocolic. And this is what, uh, talking about. So, uh, you know, it's important is the, uh, right colic vein and, uh, gastro, uh, drain into the gastrocolic trunk, which can drain directly into the S M V, which easily, as you know, becomes the portal vein. Uh, and obviously the right gastroepiploic vein also drains into that. And this traction onto this can result in injury here or avulsion here. Avulsion here isn't too much problem. It's easily controlled. Uh, if you can get, but typically the length and the variation that me here is great so you could have it going directly into S M V. And if if you were to apply the clip quite liberally, you could damage the the or the most equal liberal, you could damage the S M. V. And this can call you a lot of heartache. So, um, I've tried to put all this together, uh, and there is some audio in this video, but I'll hopefully be narrating over this. You don't have to suffer through an American accent. Um, so this video is put to electronic how we'll be moving on, uh, step by step, to just go through some of the features I mentioned, uh, with with the video, keep through the objectives, indications and planning. Uh, and this is just a little setup thing here. Yes, to moistures will make your life of any assistant and your your your this stuff much easier. But it's entirely possible to use one monitor, and frequently we just use one monitor. Uh, and and you know, typically you're going to be on the patient's left hand side. So it's important. You just need to have the mountain, the stack on the patient's right hand side. You don't have to have the leg split. Uh, especially on the right sided operation. You can you can have the patient, uh, completely supine. Um, and obviously, you'd be going in the first stage of the operation going a little bit of head down, perhaps a roll towards the right. You're I mean, you're right, as opposed to the patient's right, um and, uh, and that will be That will be it. Um and we'll move. Just skip past these. Uh, yeah. So, again, you don't have to have, um, you know, typically, you you don't need a further assistant. You can have the camera operator holding holding the retraction point. Um, and that would be, uh, retraction. And that would be perfectly appropriate. I use third degree camera, uh, so they can always slip the lead in if they need to get angles or, you know, hand over the retraction to the scrub nous for for a brief second while they're fiddling with the camera. So having a a second assistant is entirely unnecessary. Uh, unless you're in the States that you can charge more for your assistance, Um, and then we move on a bit more. Uh, yeah. So we talked about the port placements here. You can use this particular port placement with a 10 and 35, especially if you have a five millimeter camera. So which so when you put your camera, you can move on, uh, to one of these ports. Uh, while you've used a stapler through the 12, but But through the 10, if you were going to intra, uh, you're going to find a stapler, uh, intraabdominally to control the vessels, but you can use hemlocks. Then you can use you know, the hemlocks go through 10 or 12 port. Um, yeah. Okay. So the approaches as we mentioned, uh, you know, you can go very, very various. Generally expected, we'll use the media to lateral approach, which starts off with the information to trickle, you know, in for a colleague dissection. Okay, right. So we're just through these, uh, we'll move on to the past reports, and here we get to the, uh, college vessels, as we mentioned. So this is back to the picture. We identifying all the structures. Um, and here they've got a middle colic arteries. You don't always see this artery. Uh, the right branch, the middle colleagues Not not always there, as you know. Um, okay, So, um and typically that the the adhesions of the terminal to the right side, and that's, you know, it's entirely puffer the course. So you want to get all the bowel out of the way, and you don't have to identify the ureter in the external iliac in every operation. It's rather unnecessary, but going onto the operate itself, So you've got the assistant putting tension here, and, uh, so that you can get underneath the, uh how's your colleague vessels? And here is important to recognize these. These angel has these, uh, these fibers here and that usually tells tells you the plane, uh, you know, there's a plane in that area, and it's for you to try and develop that plane, so yeah, tension counter tension. Of course you can. So they're typically your left hand is lifting up. My right hand is trying to push the other layers down, always keeping an eye where the duodenum is because that's going to be help you identify where you know, try and limit the damage to duodenum and especially using energy instruments. You have to be mindful of thermal transfer to the duodenum. As you can see the duty, um is already starting to lift up here. So you want to try and bring that duty? Um, down as the surgeon will do. As you can see here we have an all sign that's telling the surgeon A You're in the wrong space here. You need to find, uh, the space above you. That's for the surgeon has gone above us and try and drop that layer down so that he recognizes that that's not the right area. Has to be a bit higher and push the line of tilt down. So and here, the whole idea is this is to identify a nice military window there, end above the duodenum, uh, that you can then start skeletons in the vessels so that you can apply various things ways to control the vessels. So you identify the duodenum, and in the states, you can just, you know, they prefer to just use a energy device that can go through all go through the vessels in the UK Typically, you know, we won't rely on the energy device for this. We would use a clip or or a stapler, even though those energy devices are perfectly acceptable. And here is perfect demonstration of the sign again, going back a couple of seconds big Oh, here telling you you're on the wrong space. Go above you, and he does and drops this. And and, as you can see in a very thin patient, uh, the you know, it's just a millimeter difference, and you could be in the wrong space. So it's important that to recognize when you're in the wrong space and get back into plain and here you want to go as high as possible towards the liver and you can see probably the outline the gallbladder coming up so you can see you're heading towards the gold out of the we've got a quite ability here again. It's all very, very, very, very thin in here. Uh, and here, if you want, if you've got a right branch, then you probably take it just otherwise you will not get the ability. And that requires another clip or energy device, which they're doing you doing here okay. And heading towards the, uh, gold brother. And the next step, they have chosen just the lateral attachments. Uh, I typically, you know, because I'm in the area anyway, we'll start, uh, towards the start towards the on the superior attachments, uh, by the liver. Important note. Here, look, you've got tattoo staining there that tells you it's likely either a very small, improbable tumor or a polyp. And you know, they've used preoperative tattoo that some of which you're staying into the abdominal wall. So doing the lateral attachments here, that's the appendix, and you can probably just about see when they get to here there will be some gas or bruising behind. There you go. There's some gas and bruising behind the, uh, colon there, and that's because they're going to meet up with the, uh, inferior or middle dissection. As you can see, he's met up with the middle dissection, and it's just retracting the colon away from the abdominal wall while dividing the attachment's. And that's essentially what you do. Just protracting here. Your assistant will be holding onto the appendix like he's got the assistant he doing and pulling up right up to the left upper quadrant so that you could get all these fibers cut once you've done that and you know you. So he's come around from the bottom. But you can also come around from the top, and then typically, you've got to mobilize er, the the the the terminal ileum Uh, and and that's just, you know, just so they can get length of delivery through the wound. Uh, it's just fairly straightforward here. Just stick to the bits that you can see through and generally get across now, bit you can do it either Interco, Perrelli or, uh, extra corporal EI either inside the abdomen or outside the abdomen. Um, typically, if you've got someone like him where of this patient where you are? Uh, you know, this will very easily come through the wound. Then there's entirely unnecessary to do this. Uh, Inter Corporal e you could just deliver the entire, uh, right colon along with the momentum. Um, uh, you know, one of the bits of momentum, uh, through the wound and then do that division on outside extra co poorly. So I will skip past these bits, and these are the lateral attachments here. Um, and once you've, uh, you know, it's clearly that he had gone through all of them. Uh, and he is going through what's left behind. It's important not to put too much structure than cause bleeding. Um, and again to make sure you're free from any other attachments, especially to the gold brother without damaging the gold brother. Okay. Okay. So then once you confirm mobility, uh, specimen out. Typically, there will be a grasper on it, so you can see here. There's a grasper just coming into view there, and you hang onto the grasper, uh, usually in the appendix and deliver the entire specimen out once you've got the entire specimen, Uh, you would do a your resection anastomosis. So there you go. Tattoo over the two marriage, psb palpable. And and then the anastomosis I showed earlier firing the stapler, uh, in your antrotomy and then followed by a cross stapling. So here they've used a ta or T x stapler, which, uh, fatture staple, but does not, uh, cut. Uh, so you would have to then use a knife or a pair of scissors to go across the top. And this is because the when the staples came out initially, there was some advice, uh, where it's not, uh, advice not to use the linear cutters. The transfers linear cutter staple is the ones that you saw earlier as across stapling device, because the risk that the advancing blade made damage, um, damage the anastomosis or the other blader state Rosa Staples. Um, and call obviously potentially least leaks. How this is, uh, in my experience is, uh, extremely unlikely. Um, and yeah, I mean, however you choose to it, it's absolutely fine as long as you close the antrostomies. It's important here that you can see they use multiple multiple multiple clips and Babcock to try and make sure that that no part of the enterotomy slips below your staple because that will be disaster, cause you know, the big hole, uh, in your Testim ASUs and and and then you're scratching your head how you're going to sort it out. And and there you go. That's the final outcome. Uh, so, yeah, they use a pair of scissors. Uh, and typically, at this point, you may all have a bit of bleeding from the edges. And that's usually a good sign that tells you that you've got healthy edges, uh, to to to, you know, on your nose, nemesis that your anastomosis well, vascularized, um, the fact they're doing most of this outside the abdomen tells you there isn't a lot of tension so that they're adequately mobilized again. You don't want to be, you know, doing the anastomosis right down the depths, but rather up here again to show that you've got enough mobility. So if you do get a bit of bleeding, Yes, you know, you could just, uh, either spot weld them or in my preference is to just under run them a bit of pds. Um, and that generally does the trick. And this is the final outcome. Once you dropped everything in and check for for bleeding, you can take the ports out, close the patient up, and this is what you are left with. Okay, so you move, move on from that, um, two Harmans procedure. Oops. And and I've chosen Harmon's because it's it's fairly straightforward and easy to describe and explain, uh, the steps for laproscopic Common's procedure. Uh, it's it's pretty much the same, uh, a high interior section, except would be anastomosis uh, the end of it as opposed. And you could just go further wrong. And do you? If you were to do depiction, then it'll be a low interior section. Uh, the right. How so? Moving on here. We have again diagrammed the colon, and this is after the operation. You can end up with an N w end colostomy, uh, sigmoid and the top of the rectum's going to be resected off, and you have the staple end at the top of the rectum. Uh, but if you go to an estimate and doing high interior section. Then you probably end up the nest Imuses here. I mean, the Hartmann's operation, although typically done for diverticular disease, uh, present is first described to sing with cancer. Uh uh. He noticed that, uh, after operating on, uh, sigmoid cancer, his patient lived, Uh, he had quite a radical operation, but, um, you know, we've then distilled it, uh, to essentially a sigma colectomy and end colostomy. And typically now an open Harmon's is generally for a, uh, generally be done for a perforated sigma diverticulitis or emergency resection of unobstructed cancer. Uh, an asthma is is not preferable because of the size discrepancies and the of the colon and the rectum, but also the the physiological disturbance of the patient. Right. So, again, going to the operative anatomy, uh, it's again. It's important to understand layer we need to be in, and that's marked by the blue line. Here. We want to be again right underneath the mesentery onto the, uh, coats line of Taltz fascia. And you want to be able to raised and return the colon right back into the midline. You don't want to be underneath the vessel, systematic vessels or natural vessels. You don't. You definitely don't want to be underneath the Yuri to, because that will can get caught up. If you, uh, need the ureter, then the your it'll be pulled up in yours. Your, uh in your in your dissection potentially resected. And it's a bad day in the office if you make if you resect through the ureter and obviously try not injure the high lax in the process. So again, the more mobilization as we come through, we'll go through a medial collateral approach involves getting in front of the HIPAA gastric plaques is leaving the nerves behind, which is very important, especially in the mail. Uh, but also for bowel and bladder function, uh, going underneath the vessels, the info mesenteric uh, sorry. Going under underneath the mesentery. Uh, making sure that you get the info mesenteric on your left hand side so that you can deliver Go medial to latter on the dissection and deliver the miso colon, uh, away from the rest of it's of it's, uh, attachments. And then once you've got that space and you've dropped the vessels down and this is again looking from media to lateral, so the camera is looking from the patient's right hand side towards the patient left hand side. Um, this is the or, you know, this is this is the aorta. And this is the information trick artery. We have dropped the the the nerves down. We've dropped the the the ureter down for this view where you can see the vessels and then the superior rectal come up here as well, and that will help you be in the right space. So the setup is similar just practically on the opposite side. Um, you'll have the operator and assistant on the patient's right, the laproscopic stack on the left. Now, if you were to get another assistance, So if you're doing, uh, a terrorist section, uh, then you may have another assistant on this side, uh, lifting the colon, but also in patients that have, uh, very floppy sigmoid that have very fatty epiploic. Uh, sometimes, you know, you can't get enough mobility more on the sigmoid. Sorry if attention sigma to get into spaces. And therefore you might need a second assistant holding up the sigmoid, helping you hold up a sigmoid like a curtain so that you can dissect underneath it. So the first set up in the procedure is once you get your ports in as described before, uh, you, uh, have not shown your ports other. You, uh, you have a 10 12 working port. Just both the a cyst on the right hand side, another five working port and another five retraction port. And as a little little earlier, you know, you could have another five port. I mean, you can have this port bit higher. Another one here just to help you raise Raise the, uh, the colon like a curtain. Um, so the first step is to get the small ball out of the pelvis. Go steep, head down. You want 20 degrees of head down ideally, um, but, you know, whatever the least amount, you can do it without get more civilization to get good visualization and not give you any status. Too much of, uh, headache. So you want to identify the sacrum? So you I didn't find the bony landmarks because I'll tell you, we can make incision, identify the i m. A. So that you get you do that by tenting up the the the, uh, sink colon. Uh, and once you've got the tented up, then can make incision. And I'd be looking for this hair white angel hair, Uh, and they'll tell you you can identify the TME plane from there. Um, which obviously, we'll be entering too much because we're doing a harmony just as a good starting point so you can start from there and work your way back, and that's usually a good, good way to do it. Um, because what that allows you to do is to make sure that you're not either too deep or too high, uh, which you would get into bleeding. So if you're too high, then you end up going through the mesentery, you'll end up with lots of bleeding. And that can further because you more heart ache and pain, because that will, uh, stained those planes and make the subsequent dissection more difficult. So, ideally, you you want to make sure that you call the entire mediatory above you and the hypogastric plexus below you, and ideally and obviously you need the ureter and the gonadal vessels below you. So once you vision and you get your left hand in and lift up and what you're hoping to then drop down is to have a view like this you want to. Obviously you want the I'll ax to be on the floor because behind the eye, relax. You're a big problem. Uh, you'll see the ureter pulled up like this, and you want to push that down. The best way to do that is actually go the layer above the jury to the U and push that layer down, as opposed to trying to skeletonize years. So she end up with some bleeding and the gonadal vessels in the left hand. Here, you don't want this to be in the left hand. You want your left hand to be here is you can appreciate. There's a plane just above the canal vessels and then your right hand to then drop the yoga nodules down, and usually they come together. The package. You don't have to separate these two layers like this particular surgeon's doing here. You can drop the entire thing down, and that's absolutely fine. Uh, once you've got these dropped down and you've gone up, you'll find yourself limited by by mobilities. You're gonna go far enough as far as you can because you'll be limited by the infamous enteric artery. And here, uh, it's important to recognize that at some point at one point, you'll have to divide the inflammation track artery. But before you do that, try to do as much as you can to go up as high as you can as much as you can before you divide the infamous Nick Artery. Because as soon as divide this this bit of tissue and tension here is what's stopping some bit of small bowel than flopping into into your into your space here. So, um, you know, the more you can do without your bowels small bowels flopping in is better. But eventually, at some point you'll be limited mobility. You can see here small bowel mesentery just sitting here with a small bowel there, Um, just waiting to come into your operative field. At some point, you have divide. So, you know, here they've applied to hemlocks or two on to the side and staying with patient one to the side of specimen and then a division between with an energy device. Here, the target of the instrument of choice seems to be a harmonic, which is an ultrasonic, uh, energy device. So once you've provided that. Then you can lift up immediately left hand, and you can then start tunneling your way. Uh, as high as you can towards explain. Once you've done that, it's a matter of then going above your dissection, getting the colon, then pulled onto the towards the right and then doing the lateral attachments. Uh, until you get to the distal transverse call on and then just if necessary, you know, in a heart mints unnecessary to try this because you probably have length at this stage. But if you're doing an anterior section, especially resection, you would have to formally mobilize the Hispanic flexure, which obviously would involve coming at it from both ends. Both left hand side but also going from from medially towards the left Left. Naturally, uh, were involved getting into the lesser sac, which obviously you'd have to take the the mental adhesions off the of the transverse colon. But typically for a heart mints, this would be entirely unnecessary step, because you should have enough length at that point, um, to to get your colon out through your stoma. Uh, you're expected to my side, and if you don't, then there's usually more length to be found at the root of the mesentery of the of the colonic mesentery as the the vessels beyond the I m. A will be coming from the marginal vessels. So there isn't any other major vessels, uh, at the at the root way until obviously, you come to the pancreas where they you could potentially run into trouble. Uh, generally speaking, you don't have to go that far. So, uh, once you've got everything mobilized, uh, and if you're doing your Hartman's operation, then you're now really you're not ready to get the specimen? Uh, the the the resected. I mean, the mobilized cologne out three wound and do your reception and diagnosis. Um, And if you're doing an, uh, interior section, then you will be doing anastomosis of the section now you can. My preference is usually to bring this up through the midline wound, uh, here, but it's not impossible for you to bring it out through the storm aside. But the problem with doing that through the storm side and if they're particularly bulky colon, then you know you're going to make a vision. Uh, that is, uh, mhm. That is, uh, quite wide and actually the risk of hernias, uh, past normal hernias a greater so pitfalls eurotech injuries. You can see the ureters are just They're, uh You could go only three. You could damage ureter. If you don't identify why or confident confident about ureters are, then you could potentially damage your it, uh, by either cutting through it. But if you use a staple to control the vascular pedicle, uh, potentially including your specimen, uh, you could mobilize the kidney and very easily done if you go behind the kidney. So if you don't get the plane in front of it, end up going behind it. And typically this happens as as you go away. So if you haven't quite gone as far as you from the medial collateral approach, when you come back to to mobilize it off the off the abdominal wall, you could miss yourself and go below, uh, behind the kidney. Obviously, hyper graphic plexus injuries. Uh, probably not as easily recognized interruptive Lee. But, uh, again, this is not getting into the right plane. You know, if you can see the aorta extremely clearly as if you're on top of it, then then you've got the hip a graphic plexus in your left hand and need to think again need to drop that layer back down because otherwise it's going to be part of your specimen. And the patient is going to thank you. So I've got to be going to meet the sound because we don't want to hear American, uh, voiceover, but, uh, yeah, so here they've training MRI of a, uh, of a tumor. Uh, and as you can see, that that's a tumor mark there very clearly. And this is this is going to be, you know, quite quite a It's going to be a record tumor, as you can see. Uh, and here, just pointing out the port position. So we will just skip past these because it's going to be the same. So once you get in, yeah, just have a good lapa Look around. Make sure look for any um, you can see the small bowel sitting, uh, and they've marked their inferior, uh, sorry. Inferior epigastric. Uh, so they're getting these rather shop plots, uh, ports in, um, which, you know, use use typically balloon ports. Um, and the first step, as I mentioned to get all the small bowel out of the pelvis and straighten out This thing might call on, and that's the thing Might call on here, identify where your tumor is ideally and then get start incisions. So, as you can see here, they've straightened out the the colon, uh, potential of sigma. And they've identified ways and they're going to make the pet incisions here and here. You just want to make a petrol decision so you can just identify where to go. And again, they're struggling the small bowel here. Yeah, so now they've made personal incisions, and now the next step is to get your left hand in to raise the musical on up and identify the right plane to be in. That's what they're going to do. And there you go, very easily done. And just trying to the right plane. They're going to try and provide that that thing there, Um, and hear what they're trying to do is just to make sure the right plane in a very thin patient like this very easily can be the wrong plane. Uh, he's identified The source tendon is a little bit to clear, so he's going to see there's more layers that can come down and so you can get above it. You can see here, there some vessels coming to view. So yes, trying to defy whether those vessels are part of the mesocolon or whether they're part of the of the nodules, and he's going to try and try and work out what they are. Uh, I suspect you'll have these identify the ureters there, which you can see just coming across there. And he's clearly identified the space. And there you go. That's interview on the other side, and he's dropping all these on. And this is the This is the cave and your left hand is doing the work. The right hand left hand is lifting up and your right hand supporting it and then pushing things down or dividing things down. So that's the ureter again. If he's normal, really, Just see just coming to be there. He he's asking his assistant to try and give him better attraction. Something stops and bleeding, and I swab that to help you identify when you come across the other side to get back into the end so you can use a sob, Um, and that will help help you get back inside or if you fell off and you can just find it that your bruise on the other side. Okay, so he feels that he's done enough, and it's now going to try and do the lateral attachment. So he's going to pull on the epic Lloyd care immediately. Yep. Oh, yes. So he hasn't done the vascular pedicle yet. Sorry. So he's, uh yeah, he's going to try and get the vascular pedicle now. So let's belong. And yeah, so he's identified the vascular critical there. He's got in his left hand, and there you go. He skeletonized it applied some and then divided in between again now, So now he's going back to the cave to do more dissection. So now, once it's divided this, you can see all that small bowel waiting to just flop in. Uh, it's important to try and get back onto your target as soon as you've gone through this vessel. Okay, Right. So now he's going to try to lift up the cave again, develop the cave again, and yes, you can see that's the ureter here, and you want that down. So he's going to drop that down. He's gonna get his left hand and lift up, and you do more lifting up there, right up to the ceiling. Typically, my instrument is almost bending at this stage. The left hand instrument, and he's recognized. Well, there might be something that I don't want to take. He's going to push that down, and that's actually going to be the the probably gonna dull vessels. As you can see, the comment is a package. You drop all these down, Uh, and you want to do as much as possible here, and that's the source tendon behind it. You don't always see the source. 10. But if you see the source, then very clearly, then you've got the ureter on your left hand because you've gone underneath underneath this, uh, you've got underneath the place here. If you see the source, then very clearly. Then you've potentially got underneath this, uh, your package here and brought it up in your left hand and you can see the tendon very clear. So you have to be mindful of that. If you see that source, then very clearly. Then you have to be you think again. But as you can see here, Even in the thin patient, there seems to be another layer in front of the store standing, so that's usually a good sign. So excuse me. Um so he's put a little, uh, swab there so you can find it again. It's not going to lateral attachments at this point. If you can hand it over to your assistant. If he's particularly experience in laproscopic surgeon, try and do some of these. It's a good place to start, uh, typically attachments, uh, to the public side wall here, or the the or the brand Wal Sidewall. And, you know, just a matter of getting these attachments off. It's important to to understand there's a double full of peritoneum here, so this taking it off, the person in here will not. Actually. Getting into the space, in fact, gets you in the space between two ends of peritoneum. So you have to go into the potassium again. Um uh, and as as you'll see and it's important again not to get get lost into the bottle wall here. As you can see, that plane is not the right plane that will take you into the wall and you'll be lost. So this is what I mean, the double for if you go back just a second. Yeah, the double fall of protein. Um, so So you've got one attachment here and then another attachment below that. So you'll get into a space into a little pocket here, which isn't, You know, which isn't where, you know, isn't the space you you think it is. There's another layer below it that will get you into the space that you want to go to. Okay, so once you've mobilized all of this, there you go. You can see. Start seeing the bruise. That bruise there. Just here. Now, once you inside that bruise, you'll get into this. You'll join up with the middle middle section. So obviously, you're going to clear up everything. You can see gas bulging through that layer, you know, very impatient. So speed this up a bit, and he's going to try and join the dots. And he has that. No, um, as soon as he gets through this layer, just one more layer and he'll get into the space. You can see he's already on the space above that and keep moving this along. Obviously, the female. You've got the ovaries. So this bit now is what I call the sticky corner. Um, so here it's important to recognize dealing with. So along here you would have the ureter. Uh, it's very important that you don't damage those. Um, so the way to deal with this is to make sure you've got the colon retracted up and your left hand ball or taking the in this case, the tube and ovary away from you, Um, and dividing personal attachment. So we'll just be this on a little bit. Yeah, And there you go. And you'll get to the point. And for me to show you this is a very common place to injure the ureter, and and you'll see that coming interview shortly. So that's the source. And then if you remember, when you were on the other side, the ureter was needle to that, Um, and you'll see that coming to you. Now, There you go. That's the urata. So if you're liberal with your with your when you dissect here, potentially injure the ureter, so stay close to the colon and you want to push the ureter away from you so that it stays with the patient. Oh, you found your other side. You're going to carry on the dissection. Uh, they have made a little serosal injury here with with the energy device. So they've elected to fix it, Obviously easily done to try and avoid if you can. And yeah, we'll skip the fix. And that just goes to show the the, uh, sort of. Sometimes the hidden danger of using an energy device is that you have potentially lateral spread of energy so you can energy can spread laterally and damaged tissues that you don't want to divide or damage. Uh, and also these blades get hot. So some of them, you know, the active blade in the harmonic, the black bit. Uh, it's quite warm. And when you when you close this close to colon, you could potentially cause unnecessary or unwanted thermal injury. So what I typically do is I grab it apparent name up here, and that will cool. Cool. The, uh, cool the the instruments so that I know that's safe to put in next and clothes on. Yes, you do end up with some, uh, you know, sort of marks on the peritoneum, but these are completely, uh, little consequence of the patient. So once you mobilize everything and you've I got away from the sticky corner, so you're you're rolling the colon up and just pushing aside and ideally hear what you like is your left hand going into that space and pushing everything away? And so you're rolling things away from you and then so you can get get into, uh, so you you can have assistant doing what this guys' left hand is doing, and your left hand can be on the other side just pushing everything away and protecting these the and that should bring you into the TME plane on the other side. It's just about to end, uh, which is, you know, for those of you who are on aware a bit more Junie, perhaps it's the total mused Eric, uh, musical excision. Um, and that's what we use in the in the for Want to get into the plane, uh, of the rectum. So that's the total total Miss rectal excision plane, and you don't have to go very far here. Uh, you just have to just divide, straighten out the rectum. So that's a T m E plane there, Uh, straighten out the rectum and just divide these adhesions attachments here, um, so that if you're bored doing anastomosis, uh, that the staple gun has a straight shot without having to go through those kinks, Um, or in this case, you're doing Hartman's. Then you don't really have to go too far, but just far enough so that you can identify the distal limit of your section. Um, And if you've taken, you know, in the cancer operation you've taken the the liquid particles high or close to its origin, then you've also taken the super erectile. So then you'll have to take the top of the rectum so that you have that you have adequate blood supply to the rest, director. So once you've done that, um, I didn't find where your margins going to be, and here they're doing it. The reflection, which is absolutely fine. Um, just above the reflection at the promontory. Rather sorry at the promontory, which is absolutely fine. Uh, then you want to separate. You want to make sure that you can get in front of the rectum, so that means dividing the mesorectum entirely. But also you have to divide the visa rectum posteriorly So was speed through these processes here, Um, uh, if you're doing it much lower down, you obviously be careful of the vagina. But obviously, we're not doing a low interior section in this particular operation of all this guy is getting pretty far down direct. So once you identify where you want to go, you then start scrutinizing the the the the end of the rectum again. Here. You know, this is this essentially, uh, this is essentially a Harmon's style operation for a rectal cancer, where this is the right up to, um at the top of the rectum approaching the midrectum here. So he's, uh, dividing the NTM mesorectum. And then that's joining up with the potassium is erectile dissection that he's done previously there. Getting through all of these. And at this point, once you've got a bear muscle tube, you can put your staple across and ideally, get in one staple, which he looks like you might without catching any of the lateral side wall attachments here. But it's no real disaster if you don't get in one staple. It's done here. He's submitted that bit, but, uh, he's deciding that it's probably okay. And he's gonna bust through it. Uh, you know, if you're unsure, then you know, just another staple. Really? Um, probably the best thing to do, and then you've got hopefully everything mobilized. Uh, yeah. This is what I meant to get length, uh, in fairly, uh, and that Would that should, you know, if you're struggling for length, just go and divide these bits. They generally don't have any major vessels in the Obviously be mindful of going the wrong plane. Because obviously you got the ureter, uh, just below you. And that's the so yeah, uh, you're getting more length again. That's the intersection. And that's the I envy their, um, occasionally, if you're doing a well, actually, if you're doing a low interest section, the I envy will be the one that's limiting your length of your colon. So you may have to divide the envy there, but they they have elected to divide the envy there. So because why not? I assume, um, and obviously, then you can then bring up the side way where you want to bring your stoma. Um, especially if you're respecting that. Okay. And once you've divided the colon. Once you, uh, divided the music hall on, you can fire staple across if you're doing a Harmon's, which they're doing here, and then bring up that end through your predetermined stoma site, that's a stapled end which they're going to bring out through your determined storm aside. Okay. Uh, right. I was hoping for this to be under an hour. Uh, just go on a little bit over time. Um, hopefully there isn't too much convenience. Uh, I just need to move on. Yeah. So in in summary, you know, that's what I've hopefully done today is, uh, appreciate varied wine very crowded. Uh, for those for the medical students and the very junior doctors who haven't been to theater yet have an idea of what laproscopic surgery looks like. Uh, and what the steps of the operation are, So you could follow that operation. You come to a corrected theater, Uh, and for those in training to do these operations, but the early stage have an idea of some of the steps of the pitfalls Some of the tips and tricks you can use and further those who are already doing these operations. Then, uh, hopefully, uh either in the presentation or, uh, in the question answers that will follow. Um, I can answer some of your questions regarding additional and tricks. Um, and that's that's everything, right? So I will close this presentation and stop shouting this and hopefully get back to this, right? Um, yeah, thank you very much. Vision. Uh, it's been an interesting presentation, and I'm sure we've all lands. One of two things. Um, from what we've seen so far, you've got a few questions in the chat box, and I would just start with the first now from cholalicum. The first question says, thanks for the enlightening presentation. In your experience, do you reckon a G I 60 will suffice? The divide Both transverse colonial Islay, um, at a single firing. Just wondering how to approach those cases with lots of chunky bowel fats making it bulky. Yeah. So, um, typically, what I used is either 75 but now I've moved on more to a 100. Um, and that generally, you know, this is a T l c g I A. Whatever, Uh, that typical give you enough. Enough length. You don't really want to be having to have multiple firings in you for your cross staple, which is where you would be doing your I'll e m and transverse colon. Single fire. Now to try and reduce bulk. What you can do is take off their prep long. Okay, so I take a skeletonized the call on, uh, typically the Islay, Um, especially in the interme esoteric border doesn't have much, and and obviously, you will be firing the stapler at the edge of your of your of your Ms Derrick division. Now, what I've begun to do is is to be fire. Uh, start firing as close as possible to the minister gauge because I want, uh I don't want a segment of my of my, uh, of my, uh, small bowel, uh, to have to be de vascularized. And if I were to sort of, uh, droid in paint, uh, it might be maybe a bit better. Let me just see if I can, um, share my screen again. Um, So, um, let's make this a bit thicker. So you've got your your transfers called, Uh, and you've got the small bowel here, and you've made, uh, I'm I mean, I'm assuming, you know, you've you've done the, uh, restriction. Lastimoso. So you've taken off that bit. So you ended up with you. You You've done your antrostomies here. Done. Antrotomy is here. The amazing tree goes up to here and the mizzen tree goes up to here. Um, now, ideally, you want to skeletonize the employees case. You don't want that. And you want to fire your staples right underneath this, and you might take a cuff of a little cuff of, uh, small bowel mesentery. And that's absolutely fine. And typically, a 75 should be absolutely sufficient. A 60 I would say two small, probably too small, especially with the chunky Coghlan's you have, but, you know, perfectly fine to use 100. Uh, and and and And now I've moved on to using 100. Uh, and that means that, you know, if you have a long anastomosis here with the risk of stenosis, Well, but also allows you enough space to get through this. But again, whatever is available, available uh, I would prefer 100 about happy to use 75. I wouldn't use the 60 uh, next question. I hope that's answered it, but feel free to chat back if you if you want more clarity. Yeah. So, um Oh, Lala con if you if you If you're not clear about that, you can put that up on the chat. Yeah, you said thanks. So I believe probably that's that's answer the question. And a second question also from CHOLALICUM. Says, um, do you have to make a bigger incision for the extracorporeal anastomosis compared to if you were using N d g eye for your anastomosis and only need to deliver specimen with a 45 centimeter incision? Yeah. So, um, that's an interesting question. And it's a very good question because I'm you know, I'm now starting to think and training on on the robot. And, uh and, you know, one of the advantages Robot of offices or inter corporeal estamos is, um uh much, much easier, More, more, more, uh, sort of, um, dexterity. Uh, but yes, it's perfectly possible to use to do intergroup oral anastomosis. Uh, staple anastomosis. Uh, laparoscopically. Um, Now, typically, in my experience, the limiting factor, uh, for for the size of the incision is the size of the tumor. Now, unless you have an extremely bulky aumentar, uh, the the tumor if you have a large tumor, that is going to be the widest point. That's going to be the biggest non compressible point because the rest of the colon is compressible, assuming you've given bowel prep and you know they're not full of stool. Um, if not, give a bowel prep, even if they've got a little bit of stool on them. Um, in someone that has a large tumor, they typically don't have lots of stool distilled to that, uh, and you can always milk additional things on the small bowel away. So So, Typically, what limits the size of incision isn't the colon per se, but rather tumor? Uh, there's a few steps you can try and try and try and make that you understand that the skin incision and the fascial incision are different, so your skin incision just has to be as wide as the tumor. Uh, really? But your fat decision can be a bit bigger so that you can deliver things you can undermine the the your skin undermine the, uh, skin incisions. So you have a wider fascial incision, uh, so that you can get the tumor out and you go on up and without having to deal with. But end of the day Don't compromise an incision. If you need to make make a skin incision, then do so because pulling on that colon will can result in catastrophic leading, especially in grass replacement pain. And also, when you've got it out, be mindful of the tension, the weight of the tumor pulling onto the mesentery that's left. They're still attached to the patient. Uh, that can also cause bleeding. Um, but yeah, certainly. You know, the whether you do inter corporeal or extrapolate osmosis, what limits the incision size actually inside the tumor and and not really tavernas most you make. Thank you, visua. Um I believe that that must have, um, answered the question. Um, mole Aleka, if you've got further questions or you've got Yeah, I think it's popped up something on the chat box now. Or just read that out. Or left sided receptions. Could you please suggest any tricks to taking down the splenic flexure get in the plane rights gets in the downward traction contentions rights without our vaults? Indiscipline? Yeah, a discipline. And we end up doing a splenectomy during on heart months. I think we've all done. You know, we've all done an an inadvertent splenectomy or unplanned splenectomy, Uh, in our times and any certain that tells you he hasn't damaged the spleen during a chronic resection in his career is probably lying. But yeah, I mean, the we don't want to damage the spleen. And yes, there are some tricks you can use, so from a laproscopic point of view, even before you do anything else, uh, you can actually start with a different position. So one easy way to take down a Hispanic flexure is to do a what we call a lateral position on. So instead of patient, patient supine, place your patient lateral your ports, you may start off with with one less port, because you're you're you're working. 12 millimeter port is now on the side on the on the table, but you can have a lateral, uh, patient. And that has advantage because when you're on the right lateral position, the explain flexure is then towards you, not away from you pulling down, and gravity is already your assistant. So gravity is applying the right tension all the time, and you can mobilize the spin laterally so you know, that can be done in 10 minutes. Uh, completes planning. Mobilization. Um, now, I don't, uh, for my one of my previous bosses I used to work for Does this routinely? Uh, it's a great advantage. And yes, I you know, I I think it's extremely useful I don't personally use Is it because you require team tender on it? Because once you've done that, then you need another 15 20 minutes getting the patient back on the supine, re draping, re re prepping and draping the patient. Um, so all of this additional time, Um but that is one option. Now, if you were doing it, the standard fashion, which is the patient supine and the tricks you can use are as follows. So the first trick is to make sure that when you go up the left hand side, uh, before you even go up the left hand side, your middle dissection, where your plane is the clearest because you started from the right plane do with when you started the precycle. So the sacrum, uh, above the the TME plane and onto the vessel, you dropped the ureters go nodules. Gerard is all down. You you know you're on the right plane. Their follow that you will see the pancreas, and that's the key. Here. You have to. If you see the tail of pancreas, the tail of pancreas has to go down if you go under it in trouble. If you If you obviously go into it, that's a bigger problem. But drop the tail, increase down and go as high as you can from below. You'll be limited by two things. The depth of your board length of instruments. But do as much as you can push the instrument and the board into the patient. Try to get extra couple inches, and that makes a big difference. Then, when you go laterally, nibble, nibble, have enough traction, but not too much nibble. Nibble, and you'll find a point where you where the colon and your left, uh, left, uh, side wall. Groenewald, meet together. Don't push beyond that. And because you know your potential spleen at that point, drop it down. Go to the top, get into less a sack, and the idea is to just meet, come from either and meat. Now, in particularly difficult patient's and we're doing laprascopically what you can do is then change tax so you can go between the legs. And that's why all my left side resections I have in the modified Lloyd Davies position, um, and go between the legs, get your cameraman holding up, put another port in the in the in the, uh, a big gastrium and then work that way. Uh, still not making progress because you just need more production there. You can move your camera to the side. You may have changes to 12, and then you're looking from a top down onto the onto the onto the the the, uh, transverse colon and momentum. One hand momentum, the assistance hand on the transit of employees k pulling trans ducal on there and you're going into lesser sacked lifting out mentum colon cutting towards explain. And that is one of the ways. Now, if you want to look into this more closely, if you look up ST Mark's, which is a hospital in the, uh, in the United Kingdom, it's quite a reknown corrected center in the world. Um, they have some old videos on on how they approach. Uh, left sided and rights are resections. Um, they have some interesting takes on how they do this. And it's always important as a surgeon to have various tools in your arsenal and having different ways to do something, because when something isn't working, you could change track and come again. But ultimately, as you said, it just requires time, patience and doing things slowly and spring fractures can take a while, you know, especially those deep spanning fractures. They can take a while, and the key to this is that if any point it becomes you're not, making progress becomes too difficult. You think you might cause an injury convert. There's always an option of converting, and you know your team will help. We'll be happy because you're not going to spend the next 45 minutes doing something. The patient will thank you because you've not invented domestic spleen and and and obviously you'll be happy because you're not dealing with a stressful situation of bleeding spleen. Hopefully, that's helped. I strongly believe so. Um, Aleka, can you confirm in the chat box if that has held and if there are still further questions? Yeah, so he said, Yeah, the acknowledge. That's that's answered the question. Uh, I think That should be okay. So there's one other question from himself as well. Um, he's just said last question. Please. I also, um what are your thoughts on being painstaking to preserve greater momentum during rights, Amy, or extend the rights? A me, especially when it is very plastered to the transverse colon. It always looks so much easier to chop it off. So, yeah, I mean, when you're doing a right hemi and you've got a bulky a mentum, you may have to to divide the attachments to the transverse colon before you deliver it. So you're not having a big bulk coming through and you can see um, But typically, what happens? Is it a bring it up, You mobilize the momentum off they call on, and then you do your section. Then you end up with this long strand in it. Flimsy looking bit of momentum, and it's usually a bit purple. Uh, well, I'm not going to keep this in because that's even if it survives, it's going to cause a fever. On day one. It's going to cause a reaction. Typically, the CRP. If you check CRP in day one day three, that's going to be a bit high, and you're not sure whether there's a problem inside or whether it's mentum that you left behind. So in my practice, if I see any dodgy looking bit of momentum, it's going off. If it's, well, nice perfume. Even if it's a bit longer, then that's absolutely fine. I'll just tuck it on top of the anastomosis and and and and hope that it does something, Um, but yeah, so I wouldn't resect it from the get go, you know, as as a matter of principle, because even if if I was doing it, if I was doing it laparoscopically and I decided just go across the momentum, then I've got all that bulk coming through. My, my, my, my, um, my, uh, extraction site. And I wouldn't I don't want that. If it's really bulky, then I would take it off. Intercarpal really doing my specimen. Then we'll look at it again to see what it looks like, but again, Yeah, it's it doesn't look healthy. I'm taking it off. If it's fine, I'm leaving it. Great. Thanks for the answer. Um, a lot of con is that Is that although do we still have more. I know you said last. Well, they last last. Something like that, or anybody else is fine. Yeah, all right. He's just said thank you. I think that might be the last question. There's no other question on the chat box. Um, I'm pretty sure that that should be all the questions for now, Um, thanks, um, to visual for delivering this fantastic, um, bowel surgery lecture and being minimally invasive as well. It's, um it's a lot of things to learn. And, um, thanks to the attendees or staying till this time, I know we've run above, um, time for they still we still we still have learned a lot from this lecture. And, please, can you provide your feedback? I've just sent the feedback form to the chat box, and we'll possibly get that in our email box as well. And, um, you you will only get the certificates if you complete the feedback form, that would be helpful as well for further folks. Just to know what we've done well, on what needs, um, improving on. So that will bring us to the end of the teaching today. And hopefully we would get some meats in a couple of weeks from now. I don't know if visuals got anything else to say. I'm just wanted to thank everybody. And, uh and thank you for, uh, for inviting me. Uh, I'm very I'm very grateful. And I hope that my talk has, uh, has helped helped somebody. Um and yes. And, uh, if there's any, uh, feature talks that you want me to give, I'm more than happy, uh, to be invited back again. Thank you very much. We really appreciate that. Alright, so we'll call these a wrap now. Thank Thanks. Everyone who stop share ng, um, two minutes in case you still have any other thing to drop on the chart box. But that would be related to the speaker, maybe via email. OK, Meeting would end in about two minutes, so just give everyone two minutes Visa. I'm happy for you to log off if you want. Okay. Well, thank everybody and, uh, thank you. Bye bye. Yes. Okay,