Welcome, welcome everyone. My name is Eitan Ribeiro, I'm a gynecologist, oncologist with the Rasta Gartner Hospital in Brazil and co-chair of the Surgical Education Group of the IGCS. So I would like to apologize, so we are a little bit late, but I would like to welcome you to today's Surgical Film Festival on Complications Management of Bowel and Vascular Injuries. We have an incredible panel today of surgeons who will be sharing their expertise in management complications. We are thrilled to have you with us today. So before we get started, I want to mention a few housekeeping items. There will be ample time for discussion today, so we encourage you to submit your questions via the Q&A feature at the bottom of your screen, and we'll do our best to address as many questions as possible. And recording will be available on the IGCS portal. Also now, it's my honor to introduce my co-chair and co-moderator, Dr. Carrier Langstrath from Mayo Clinic. Thank you, Dr. Langstrath, for joining me, and we'll hand off to you to introduce your speakers. Thank you, Dr. Ribeiro. It's my honor to introduce today's speakers. Joining us are Dr. Mario Leteo from Memorial Sloan-Kettering in the United States, Mariana Krutman of AC Camargo Cancer Center in Brazil, Dr. Fabio Martinelli of IRCCS Foundation National Cancer Institute in Italy, Tai-Mei May of Princess Margaret Cancer Center in Canada, and Nilte Caetano de Rosa of Angolan National Cancer Institute in Angola. Thank you all for providing your expertise and knowledge today. Without further ado, to kick off today's film festival, I invite Dr. Mario Leteo to present Management of Interoperative Vascular Injuries. Dr. Leteo, please share your screen. Morning or good afternoon, everybody. Thank you, Dr. Langstrath and Dr. Ribeiro for inviting me today. Not sure why I always get asked to do talks about this, but maybe it's a subtle message. All right, so today we're going to briefly in 10 minutes just go over managing vascular complications. I'm going to focus mostly on the minimally invasive approach, management, because that's usually the most harrowing. Usually open vascular complications are a little easier to handle. The principles are the same, though. These are some of my disclosures. I always like to give a talk on surgery and surgical complications, but the surgical complications won't happen if you are a busy surgeon. The only surgeons who don't have complications are those who don't operate or those who aren't truthful. So, you know, you do enough surgery, you will get complications, as you'll see some of the videos of my cases that I'll show today. Anytime you're doing surgery, the best way to manage a complication is obviously to avoid it. And, you know, really the keys are to know your anatomy, know your surgical techniques and tools, and exposure. I can't tell you how many times people are doing no dissection and just open the space a little bit and start ripping out lymph nodes, and then there's a big bleed, you can't see where it's from. So I always open all my spaces before I start actually doing the procedure. So that's the very, one of the most important steps is to expose your area that you'll be operating on, so that you have proximal distal control in case of an emergency. And obviously you're exposing your structures and try to be as standardized as you possibly can with your technique. Again, this is just a funny graphic here showing that the rate of complications is directly related to the rate of satisfactory exposure. So for many days of surgery, there's, and in surgery, there's only mainly one way you can actually kill a patient, and that's with a vascular injury that you cannot control. Everything else really is not in your hands, you know, a major heart attack or pulmonary embolism, that's not really something technical, whereas an injury to a vascular structure is. And during the only days of surgery, the majority actually happen at insertion, when you enter the abdomen. And then a smaller percent, about 83% happen at the time of entry into the abdomen, whereas the remainder is during your actual procedures. And whether you use varusneal or some other optical troch, or otherwise, it doesn't matter, they're both associated with the injury. And then, you know, there's about a 10% mortality rate reported as high as that in some series. And usually that's from exsanguination because of lack of control of the bleeding. And there's this very rare event of gas embolism, which is highly, can result in a very high mortality, very hard to sort of diagnose definitively. And just to speak on that CO2 embolism, that's usually when somebody, you're operating, you're insufflating, all of a sudden they undergo all of a sudden just cardiopulmonary collapse. So you obviously stop insufflation, give nitrous, you ventilate with 100% oxygen. And then the key is to put the patient's head down with the right side down. The idea is that if there's any air bubbles or CO2 bubbles in the heart, it will be up into the ventricles and not allow them to go into the lungs and brain. Hydrate, and there's a bunch of things here to do. This really requires coordination to anesthesiologists. And I'm not going to say much more about this, but it is a pretty dramatic event. And if you ever have a patient while you're doing intubation surgery, that all of a sudden just has cardiopulmonary collapse, you have to put this on your list of possibilities. Now, when you enter the abdomen, as I mentioned, that's the majority of injuries. You can injure first the abdominal vessels, mostly the inferior pegastrics. And so it's important to know in general where the inferior pegastrics will lie. And if you look at this nice diagram here on the right side from the midline, these are in centimeters from the midline, as you go from pubis up to the xiphoid, you can see the general, I mean, there's always variations, but generally this is the course of the inferior pegastric vessels as they enter the rectus muscles. And you can see here that, you know, once you hit between the umbilicus and pubis, it's about five centimeters from the midline. So that's why I always like to show this, when you use a robot, you'll never injure the inferior pegastrics. I can't remember last time I've injured an inferior pegastric now with the robotic placement. With laparoscopy, everyone has this sort of desire to put the trocar so in the midline. I've never understood that so very low. It's a cosmetic argument, but I don't think that's the safest way to put trocars. But be it as it may with the robot, it's really never an issue injuring the inferior pegastrics. However, if you do injure the inferior pegastrics, there's multiple ways you can do this. Often many have many people have the tendency to start ripping out the trocar. I would actually recommend not taking the trocar out so that you can work around the trocar because it will actually help in tamponading some of that bleeding. And then you can just use an old fashioned Carter Thompson suture passer here. As you can see, there's reusable ones, there's disposable ones. You can use, I forget what it's called, there's a disposable one. And you can really just try to pass the suture as if you're closing the fascia around the trocar and then as you tie it, pull the trocar out. Another little trick that I've used once before is you can actually pass a Foley balloon, Foley catheter through the trocar and then inflate the balloon and just pull up the Foley and then put a clamp at the skin. This will often tamponade these vessels and you can continue your case and then reassess at the end of the case to see if there's any continued bleeding. So these two little tricks are pretty easy. Worst case, you know, you have to stop and make a bigger cut down and try to find the bleeding vessel and control it directly. But really that should not be a very frequent occurrence and often you can manage these this way. Then after the abdominal wall vasculature obviously is the great vessel injuries which are very dramatic. So knowing your anatomy again is very important. How you enter the abdomen, also you have to be very careful. There's talks about angles of how you enter with your varus needle or whatever way you enter. Honestly, it doesn't, in my experience, it doesn't matter. As long as you are careful and follow the proper techniques of entering the abdomen, you should hopefully have very low to almost no great vessel injuries at the time of insertion. You can then also get great vessel injuries while you're doing your procedures and especially for us as gynecologists, that'd be mostly seen during your pelvic and periuretic node dissections which thankfully are very few and far between now. Doesn't matter what you do open or varus needle. You can get an injury of these great vessels with any of these tools. So when you do have an injury during laparoscopy, it's very important to immediately recognize the injury. Hopefully you've exposed the area well enough where now you're not only having to deal with a bleeding but also having to now actually expose the area which is very difficult with a lot of blood in the way. It's very simple. Just put pressure on like you would open. Put a little Ray-Tech in or a little sponge that fits through trocar and then you just ask your assistant if it's laparoscopy or with your robot arm just just hold pressure. It's that simple and then start to think about your other options and then try to figure out if you're going to be able to repair this minimally invasive or if you need to call for help or if you need to convert to laparotomy. You can also just especially with the robot just come across and grab it if you can see it well enough. It depends on on the location of the injury whether you can actually grab it or not but you know having a Ray-Tech in and holding pressure is usually the first step until you sort of figure out what to do next. I'm not going to show this video for time's sake. It's really if you're doing laparoscopic suturing and you it definitely and trying to do knot tying is sometimes a challenge for some. Not all. I know there are great laparoscopic surgeons out there but the little trick that you can do is if you just put a laparotie on the end of the suture. This is a 4-ovicle on a that looks like an sh needle. It's not my video. You can just put laparoties or a eclipse on the end of the suture to avoid the need to do knot tying and then you do that when you pass the first one on the end and then when you go to instead of tying it when you hold the suture up you can put another laparotie across the suture on the vessel to hold the suture in place and this is a laparotie device that's out there for laparoscopy. This you just put on to the end of the suture and this avoids the need to have to you know struggle doing knot tying. The other little trick if you don't have laparotie is just use hemoclips and what you can do is you can put a little knot on the end of the suture here before you pass it through the structure put the hemoclip here so it doesn't slip pass the suture hold it steady and then put two clips on the other end. So that's another little trick that you know you can consider in a pinch. You also should be familiar if you're a surgeon doing working around these great vessels you should be familiar with vascular instruments both open satinsky clamps on top left and I know there's a vascular surgeon here and she may be laughing at me because I'm or she's obviously a more expert at this than I am but just for basics you know just for an emergent situation and what's very we have a vascular tray in all of our robotic rooms so that if there's a vascular emergency we can open it and all the vascular instruments are there both for open vascular control but also laparoscopic robotic. These are bulldogs that you can use during minimally invasive surgery. They're available in every OR around the world because the urologists use these routinely to do nephrectomies and you can see here this it comes with a laparoscopic applier or you can actually use the robotic instrument to open the bulldog and put it across the vessel. These can be helpful in certain situations so you should be familiar with this. Hopefully you never have to use them but you never know being prepared is more important. So you can get multiple types of injuries when you're operating. Here you can just rip a vessel and here's a video from a bar from Dr. Escobar from one of his colleagues this is doing a nephrectomy and just pulling too hard on this vein you can see here how it just rips a hole in the vein of the left renal vein. So again the first thing as you see the surgeon doing is to gain control of it. Exposure was decent I mean you can see the vessel pretty well. So you can easily with the robot this is robotic obviously you can pass the suture sort of reassess and then he just tied the suture down and was able to control this. So that was a very small relatively small hole that can be easily controlled. This is actually one of my cases from many years ago. This is an example we had done a pelvic lymphadenectomy prior to the days of routine SLN mapping around here. This patient's BMI was 40 so converting to open would have been somewhat of a challenge and this was before also they changed the sealing cover for the monopolar scissor on the robot. So I was going to stop a little bit of oozing here I was meant to use a bipolar pedal instead hit the monopolar scissor and then a hole was created in the in the external artery here as you'll see in a second. Again you know you try not to panic you gather control of this. So the nice thing about the robot is once you pull your head back you can or or take or give control to a different arm the arms will not move so you don't have to worry about fatigue of an assistant who's trying to hold a vessel and not being able to hold it steady. And then then you really clean out here's a little trick if you get blood on the camera the tendency to start taking the camera out that is the bad thing to do because you'll never get it clean enough. You wait the blood will trickle down so that you can gain control again never my suggestions do not start taking camera in and out when you when you don't have control of a vessel it will not be better. So get control let the blood trickle down enough to get control of the vessel again clean the area up and then decide what you're going to do call for open trays call for friends and then you know basically the next step was just to for time's sake I'm going to fast forward this is just a 50 pds on an rv needle and you just suture this again you know some have criticized this because I should have sutured it parallel or you know parallel to the length of the vessel in an emergency you do what you can this was years ago patient's doing fine so whatever we closed it we stopped it she went home in a day and this was nearly 10 years ago and she's been cancer free and doing great the next because of time here's a more recent injury this is a patient who had recurrent nodal disease for granulose cell tumor extensive in the periodic as well as pelvic area and some pelvic implants so we're doing an mis resection of granulosa cell tumor and you know I initiate you know taking out the left periodics we were really trying to expose I decided not to take the inferior mesenteric artery which in retrospect I probably should have just taken it to have better access and control but didn't so here we are so this is just one of the nodal this is actually at the beginning of the surgery this is our first nodal mass we're taking out you can see the left ear there the aorta this is really in that space up against the vertebral body which is just deep to this and as we're doing this we're attracted pulling up the IMA and basically I just pushed too hard with my arm and just tore the IMA off the aorta so whenever you're operating in one space all of a sudden you start seeing fresh blood in your field you gotta stop and see what's going on so as you can see this is quite dramatic as an arterial bleed venous bleeds are less dramatic but I think harder to fix and again that the concepts are to gain control before you take the camera out which we did clean the vision call for help call for an open setup in case you need to convert to laparotomy and then you know thinking this was just the IMA we tried first the vessel seal it is a vessel sealer for the robot we sealed up proximal distal to what we thought was the hole or rip this was a little more complex of an injury and after we try to seal it just continued to bleed we knew that the duodenum we had to be careful that duodenum was well dissected upward so it was away from our area of what we were doing here so it was the first thing we had done last thing you need to do is burn a hole in the duodenum of course but this we couldn't get control just with vessel sealer so at this point we decided to try to suture close it probably multiple tears probably toward the IMA but also tore it off its origin partially from the aorta again gain control clean the area up and again we I like to use 5-0 PDS but you know there's there's debate on what type of suture to use just want to use a smaller suture this is an RB needle I like the RVs just because it's small and curved well and then we basically just tied it and she did well also and then we actually finished the case MIS resected all her disease and she's remains NED currently so you know I'm over time already so I'm going to stop this and just quickly say that basics is you you don't want to pass out you don't want to panic you want to have sort of understand your vascular instruments beforehand understand how to maybe control these things and we also actually have what's called an emergency time out for robotic procedures and laparoscopic procedures where we go through this when we do the time at the beginning and the key here is to tell the whole team that if there's a vascular emergency nobody starts moving things the surgeon becomes the boss no one does anything no one rips out instruments until the surgeon tells them to we we identify who will be who is available to help as a co-surgeon it's always nice to have another surgeon attending in the room to you know just to get some support and then you know get the laparotomy tray open and all those things so we have a whole process in place which I can go over more details with anyone in the future if you want so mistakes are always going to happen during surgery and they're forgivable if you have the courage to admit them and review what you did and try to sort of make it better and make it more preventable for the next one. Thank you. Thank you Dr. Lataio. Do you have any tips or tricks for the I mean the senior or the young attending for when these things happen to that pause you know because immediately you kind of go into this fight or flight mode and you kind of get freaked out so do you have any tips for that? Yeah I mean I still have I mean I still get that way so that's it's a very if you don't get that way then I'm worried about you you know I mean it's it's a very normal thing to because again you can you can actually somebody can die on you if you don't get control so the first thing you do is you tell everybody that you got a major hole so everybody in the room knows that we initiate that timeout thing process we have a code button on the wall so that you know folks know there's a problem in the room another anesthesiologist the attending comes in if he's not there other anesthesiologists come in so that's the first thing you do when you gain control whichever way you can don't start taking out instruments ripping things out just gain control of that area if it's laparoscopic you can't grab it just get a ray tech in there and just just press on it or with the robot it's very easy to sort of grab what's bleeding you know vascular vessels can take a lot of pressure and grabbing you can actually cross clamp the aorta for open procedures for 30 minute vascular surgeon so she can obviously but you can cross clamp I mean just press down the aorta and be in a cave if you have like a major pelvic bleed during open surgery for 30-40 minutes almost and the legs will be fine so so that's the first thing is just to stop the bleeding and then you have time you like I said you can clamp the external iliac for 30 minutes before you have to worry about leg ischemia oh that's just you know statistically but but the point is you have time. You don't have, as long as you gain control, you have time to figure out what your next steps are going to be. Yeah. It's two questions in the chat. So first was what suture do you use for venous injuries? I use the same. I like just 5.0 PDS, RB needle. I pretty much use that for everything. And the reason I use the PDS is because it's smooth suture. I don't prefer the vipral because especially through veins, it doesn't pull as well. It's braided. It just pulls nicer. It's got the memory, so it makes it a little harder to sometimes manage it, but I just, but you can use vipral also. My preferred is again, 5.0 PDS on an RB. I always have them on hand. When I'm doing like that case, we have five, we open 5.0 PDS and have them on the side table, one or two just to have them available. And do you use suture over vascular clips or do you use vascular clips sometimes as well? Yeah, it depends. I mean, if you need a little clip, it's not a, that's not really a major injury to me. I mean, that's usually just some little oozing kind of stuff. I mean, the stuff you saw there now to try to clip, you can. Normally what happens, the problem with clipping, especially on the vena cava, you make the holes bigger. You have this big ooze of blood and you really can't see the hole and you start to clip. Next thing you know, the small holes become larger. So, you know, I, yes, I do, you can use clips. So I use that vessel sealer too, which would be the same idea as trying to put clips on there, but you have to be very careful, especially on the vena cava, because sometimes you can make the injury worse. You have to make sure you can actually see the bleeding part, make sure you have a pedicle that you can put a clip on. So there's lots of ways to do it. Sometimes on the vena cava, you can pull the vena tenta up and then put a clip along the vena cava wall, but you have to be very careful with that because that clip, if you are doing a special laparoscopy, you can slip and make that hole even worse, or you can rip that when you're tenting. So you have to just, yes, it can be used. I prefer to suture these bigger injuries, just get control and try to suture. Well, you also be careful when you start sucking, your assistant starts sucking, for them not to put the sucker into the vena cava and start ripping the hole bigger. I've seen that. You know, they want to be helpful. They start sucking. They get into the hole next to you, you know, they're going up. It's like, whoa, whoa, whoa, easy, easy, right? So, you know, you have to have a good bedside assistant. That's what we call, you know, I have fellows, which is great, but they're all different skill levels. So we always call for another surgeon for this case because you need a good bedside, a second assist for managing the suctioning and passing instruments. So you really do need to get expert assistance in there, not just work with a resident and work this through yourself. I mean, unless you're a vascular surgeon, I guess, then you do that all the time. That's your routine, but. Yeah, and then one last question. Do you ever use proline? You can, there's no reason not to. I think proline has a little more memory than the PDS, but I don't think it matters. Okay, great. Well, thank you so much, Dr. Lateo, and then I'll hand this over to Dr. Ribera. Okay, thank you. Oh, I think I stopped sharing. Okay, good. Thank you. It was a wonderful presentation. So I would like to invite Dr. Mariana Krutman to present the surgical film vascular resection in gynecological oncology. Good morning. My name is Mariana Krutman. I'm a vascular surgeon from Sao Paulo, Brazil. First of all, I would like to thank the organization for the invitation to participate in this event and share a little bit of our knowledge in vascular surgery and our routine practice in a specialized cancer center in Brazil. My talk today will be about the principles of vascular resection and reconstruction. In our day-to-day practice in a cancer center, we offer vascular assistance in several surgical scenarios. We usually call to help other surgical teams in anatomic exposures. We perform oncologic resection and vascular repair of tumors in great proximity to vascular structures. We perform the repair of vascular injuries in both acute emergency scenarios and elective surgeries. We perform implantation of catheters, mainly port-a-caths for patients in chemotherapy, and the implantation of vena cava filters. This is a very brief overview of the activities that we perform in a cancer center. However, for the purpose of this talk, I will focus on open vascular repair associated with malignancies. In our field of work in a cancer center, we have a long experience with vascular reconstructions in all body segments, including the head and neck, extremities, abdomen, and thorax. We have three basic surgical approaches for the resection of tumors with vascular involvement. One of them is a subadventitial vascular dissection. The other is a vascular resection and ligation of stumps. And third, a vascular resection with reconstruction. The subadventitial vascular dissection consists on the release of the vessel that is surrounded by the tumor mass through the dissection of a plane between the vessel adventitia and the tumor. This technique enables the absence of ischemia and tissue congestion. However, it presents higher chances of tumor recurrence and risk of rupture or fistulization. And this occurs because the dissection plane is not always very well-defined. And in most cases, parietal thinning of the vessel wall may occur after the resection of the adjacent tumor. Vascular resection and ligation of stumps is the fastest technical option possible. However, again, it is associated with varying and unpredictable risk of tissue ischemia and congestion due to the resection of the trunk vessel alongside with other collateral circulation. In our group, we choose to restore vascular flow in all possible cases, including arterial and venous. Vascular resection with reconstruction using interposition grafts is the preferred technique to restore venous and arterial flow, avoiding ischemia or tissue congestion. It enables and block resection with adequate oncologic margins. And it requires vascular substitutes, be it autologous, synthetic, or homologous. Autologous substitutes include the saphenous veins, internal jugular vein, femoral vein, renal vein, peritoneum graft, upper limb veins, and the SFA. Synthetic grafts include gadacron and PTFE grafts, be it ringed or regular PTFE grafts. And homologous grafts depends on the existence of a bank of cryopreserved homografts, which we don't have available in our service. Here we have an example of a vascular reconstruction in the head and neck segment, a patient with a head and neck squamous cell carcinoma with carotid invasion, where a common carotid to internal carotid bypass was performed using inverted grade saphenous vein. Here's an example of vascular reconstruction in the thorax in a patient with a thymoma presenting superior vena cava invasion, as shown on the left of the screen in a CT scan. A right innominate to superior vena cava bypass was performed using ringed PTFE graft. We prefer the ringed PTFE graft for venous reconstruction because of the more favorable patency rates in the venous territory. Here we have an example of a retroperitoneal sarcoma with IVC invasion. The left of the screen is a CT scan showing the tumor mass. In the middle of the screen is the visualization of the tumor mass in the operative field and after resection. And on the right is the final aspect after IVC reconstruction and reimplantation of the left renal vein. Here we see another example of a retroperitoneal sarcoma with IVC and aortic involvement. And on the right, the aortic and IVC reconstruction performed using Dacron and PTFE grafts, this case ringed PTFE graft. These are examples of interposition grafts using saphenous veins for reconstructions of femoral and brachial vessels. So these are tumors involving the extremities. Other possibilities of vascular repair other than interposition grafts include primary closure, primary anastomosis, and vascular closure using bovine pericardium patch. In primary closures, especially when these are performed in the longitudinal plane, they may result in vessel stenosis. So for venous sutures and primary closures, a 30% to 40% reduction in diameter is considered acceptable with a small risk of significant blood flow limitation or thrombosis. So here the dotted line represents what should be the normal diameter of this portal vein and the stricture caused by the primary closure with less than 30% to 40% reduction on the vein diameter. Primary anastomosis may be performed when there is absence of tension between the ends of the vessels. The advantages of this technique is a shorter surgical time when compared to an interposition graft, does not require synthetic material, but there is a risk of stenosis if not performed following the correct technical principles. Here's an example of a portal vein. Where a primary anastomosis was performed shown here by the arrow. Vascular closure using bovine pericardium patch is another technique that enables vascular closure of non-circumferential vessel defects, minimizing the risk of strictures or stenosis. In the photos, we can see examples of a carotid artery and a mesenteric vein closure using bovine, both of them using bovine pericardium patch. This slide shows the different possibilities of vascular reconstruction in a very specific territory, the portal mesenteric junction. This is a very challenging territory with growing demands for vascular intervention associated with malignancies, mainly pancreatic tumors. Here we can see all of these techniques that I previously pointed out, primary closure, bovine pericardium patch, PTFE grafts, and here a more unusual reconstruction using an internal jugular vein graft, where the facial vein confluence was used for the splenic reconstruction. This slide shows a non-conventional use of the great saphenous vein for a very specific scenario. In this case, the iliac vein needed to be reconstructed, and we chose to use the spiral technique for this purpose. In the spiral technique, the surgeon constructs a conduit using syringes as a scaffold, which may vary in diameter to fit the size of the native vessel. And to be compatible with it, in this case, we used this technique, we chose to use this technique because of the contamination of the operative field, which did not favor the use of synthetic material and the incompatibility of the vessel diameter with the saphenous vein on its conventional use. So that's why we chose to use this spiral vein technique. In conclusion, there are several surgical tactics for the restoration of vascular flow associated with the resection of malignancies, all of them with favorable patency rates when performed by experienced surgeons. There is no singular ideal choice. The choice depends on many factors, which include vascular territory, vessel diameter, contamination of the operative field, among many others. Thank you very much. And I'll be very happy to answer any questions. Thank you so much, Dr. Krutman. So let's open for discussion. And I have a few questions. First, regarding the suture you'd like to use for small repairs, because this is part of the things we are discussing. Do you see an advantage from PDS or proline? Which suture do you think is the best option? And which size of suture do you usually recommend for iliac vessels or aorta and vena cava? Oh, I cannot hear you. Your mic is... Okay. Okay, sorry. Can you hear me now? Yeah. Yeah, yeah. So as Dr. Mario pointed out, there is no only choice. We usually use proline. We rarely use PDS. So we, but it does have a bit more of a memory as he pointed out. But that's our choice in most cases. For iliac veins, we tend to use a five zero, maybe six zero. Venous injuries tend to be much worse and much more dramatic sometimes than arterial. Arterial lesions are easier to control than the venous lesions. But these are the sutures that we usually use. Four to five zero in iliac territories. In vena cava, maybe something big like three or four zeros. Great. So, and you said that usually larger vessels, larger veins, you can have 30 to 40% of structure. How do you measure that? There is a rule. I mean, it's more like- Yeah, it's more visual. There's not a specific rule, but by looking at it, you can estimate the stricture that it has called. So we assume like 30 to 40% is okay for venous territories. And we allow this reduction without having to reconstruct or do anything more morbid for the patient. Because the rates of thrombosis are very small if the stricture is not so significant. Okay. That doesn't apply for arterial territories. These are more for veins, just to make it clear. Yeah. Do you recommend any follow-up exams for patients who had this kind of sutures, like reducing vein diameters or no? Usually these patients are regularly submitted to post-operative because of the oncologic follow-up. They have to do CT scans or other imaging exams. So these are enough for us to control our sutures or control the bypasses that we performed. So we follow together with the oncologic surgeon. Great. There is a question. It's during a repair of the vessels, when you use clamps, I mean, probably they are asking for arterial clamps probably. So how long can we use a vascular clamp for a distal limb? Let's say external iliac, vein, artery, how long the limb can hold on? There isn't a specific time, but usually we tolerate even over an hour clamping. So as Dr. Mario said, you don't have to rush. As long as you control, you can ask for help. You just can't have, obviously, the bleeding taking place all the time. So you have to control the bleeding, clamp the vessel. Sometimes clamping, you have to be very careful because the clamp may injure the vessel. Especially in veins. So sometimes only compression is sufficient. You don't have to actually clamp, but clamping is an option. And you can, organs, abdominal organs or limbs, they tolerate ischemia for over an hour. Great. And when you have a vascular reconstruction, usually when do you start the apparentization and how do you do it? We usually do one ml of heparin prior to clamping. So immediately prior to clamping. And then we sometimes control it with the exam, the TTPA that we control. We can do it in the operating room. What we do, we administer heparin immediately prior to clamping. Okay. Do you think there is a need for heparin always when you clamp the vessel, even when it's a small repair, like Mario showed on the arteriole lesion, do you think we should use heparin on those patients or not? On a regular blade? Small sutures. If it's just a small suture, like the cases that Dr. Mario presented, I don't think there's a need for heparinization. But if you actually have to clamp and leave the clamp for longer periods, like there's not a specific time, as I said, but if you clamp the vessel and it has to stay clamping for over 30 to 40 minutes, then you have to administer heparin. Okay. And how long do you leave the... Great. So, and how long do you leave those patients in anticoagulation after surgery? We usually, for arterial reconstructions, we don't heparinize afterwards, but for venous reconstruction, especially using prosthetic material, when we use synthetic material, then we usually anticoagulate for longer periods or sometimes even lifelong anticoagulation. But when we use autologous grafts like sat veins, we don't anticoagulate for long periods of time. Sometimes only a few days after surgery, but we don't have to leave it for longer periods. Awesome, great. So that's a great discussion. Unfortunately, we have to move on. So thank you so much for your presentation. And next, please welcome Dr. Fabio Martinelli presenting management of intestinal complications. Dr. Martinelli. Hi, everybody. Can you hear me? Yeah, it's perfect. Okay, so let's start. Let's move this here. Okay, thank you for the invitation. Of course, it's a great educational course and I hope to contribute. So I have nothing to disclose. I'm sorry, I have not that much video for a video session talking about management of bowel complication. First of all, as said Mario before, we have to be aware that, of course, complication can happen to us, to every one of us. Only the one who does nothing don't have complication. From these are some data from a paper published on Green Journal, 2015. And of course, you have, first of all, identified the problem. Identify what kind of complication you can have. Usually, bowel complications are mainly due to small intestine for laparoscopic surgery. Fortunately, it's less than 1% of risk of complication in laparoscopic gynecological surgery. But of course, you can have complications with large intestine and rectum. And the most dangerous part of the procedure usually is the entry, the use of various needle trochlear insertion. But of course, you have also keep in mind that all the device you use, as said before, so Mario, for the injuries on the external carotid artery can cause damages. Electrosurgery device, laser surgery device, harmonic device, all these kind of instruments can give danger. When are performed, when are recognized and how to manage this kind of injuries? Of course, 60% of injuries are diagnosed intraperiturally and can be managed during the surgery. Of course, you can start from bowel suturing or doing a resection and anastomosis. And I think we're going to see a video specific on resection and anastomosis later on with a colleague. So if you feel confident in doing minimally invasive laparoscopic robotic, of course, it's fine. Otherwise you can convert the patient to a laparotomy. When you do a laparotomy surgery, for sure, it's easier. We are here and mainly you have injuries usually during the dissection, leases in a stuck bowel. And so you just keep control of that rarely with a resection. But I want to focus this presentation on post-op complications. So I'm going to show you some cases and how to manage. And of course, if you have any suggestion or things that could have been different, I will be very happy to answer in the Q&A points. So management of post-operative intestinal complication. Again, always remember that can happen. We have seen then the risk of complication of laparoscopic gyne surgery is below 1%, but it can happen. You have to identify the complication. So you have the patient, which is not in the OR, but it is in her bedroom in the ward. And you have to identify the complication because the prompt recognition of an intestinal complication is mandatory. It reduce the late complication, eventually death. What are the main thing you can find when you have a bowel complication, post-operative complication, peritonitis, abdominal pain, fever, abdominal distention? There are a lot of other symptoms that can have, but not always are the same. What to do? Usually when you have a post-op complication, the patient is in the ward, the thing is managed by a laparotomy. It's very, very rare that you can manage it by a minimally invasive, even if you have done a previous procedure by a minimally invasive. And of course, when you enter the abdomen, what you can do is identify the complication, direct suturing, bowel resection and osteomosis, bowel diversion, and more other options depending on the case you find. I'm going to show you some cases that happen, and these are real cases. So this is a 50-year-old that normal weight, no comorbidities, she underwent a midline laparotomy doing hysterectomy, an exectomy, peritoneal staging for a 3A endometrial cancer with ovarian mats. No problem during the surgery. She was very well on the post-operative day one. She was working in the ward. On post-operative day two, she started complaining about abdominal distention. She was, her abdomen was like a drum. She was, as a positive Blumberg, saying that she usually stayed in an untargeted position. We are, of course, it was the 1st of January, the morning of 4th of January. That was the abdominal extract that was ordered. And you see, there was a massive neoperitoneum with air fluid level, soma, colon, and ileal distention. So I think that everyone will guess that the patient needs to go to the ER. With that case, consider that on post-operative day, she was working in the ward. So we bring the patient in the ER. We do our next lab with a general surgeon, a gastrointestinal surgeon. We found a lot of air. It was like having a belly for a laparoscopy. Few free fluid that were collected and sent for microbiology, but we did not find any evidence of enteric material. So we start inspecting all the bowel, the stomach, but again, nothing. We didn't find any kind of hole. So what to do? You have a high suspicion of perforation on post-operative day two, and no idea of what to do. So we called the endoscopist. We did intraoperative colonoscopy, aeloscopy. So we inflated all the bowel, big, large, and a small bowel, and even the stomach, and again, nothing. So we ended up the procedure thinking that the patient had normal white blood count, normal PCR, and no fever. The patient recovered well without any problems, and then keep on going with our oncological plan and protocol. And three days after, came out the microbiological evaluation. It was all negative, and no culture. All the culture was negative for any kind of germs. Two weeks later, evidence. This is case two. It was a 43-year-old lady with a BMI of 35, so nearly obese. She has completed her diabetes. She has a previous two C-section, and non-relaxal mass transfusion from borderline, and CN2, and also fibromythosis. She underwent the laparoscopic hysterectomy with, yes, on peritoneal staging. The final part was borderline CN2. We did an entry access with open access, so to try to reduce the risk of injuries about the closer entry, the closer entry with the virus, or the direct entry. On post-operative day one, she start having mild fever, but always below 38, and increased the CPR and the procalcitonin with a white blight count of nearly 6,000, but Bloomberg was negative, and the patient was working in the ward. So, what to do in this case? We ordered an albumin X-ray, and that's the plague. There was some neoperitoneum here, but talking with the radiologist, they deemed it compatible with the recent laparoscopic procedure. She did the laparoscopic procedure the afternoon before, and this is the X-ray, the albumin X-ray performed on the morning. She has also some EDL levels, but there was also air in the colon. To exclude also the more frequent complication, that is mainly a urine leakage or something, we did also a CT scan, but with IV contrast, but there was no leakage, no urine leakage. So, the case was discussed altogether with GI surgeon and radiologist. We deemed it suitable for experimental management, because patient was not suffering, was not complaining about anything, and she started a wide spectrum antibiotics. On postoperative day two, the patient was clinically stable, able to work, Bloomberg negative. She keep on with mild fever, below the 38. White blight count was more or less the same, but we got a slight rise of CRP and progesterone. So, we give her something to drink, the gastrointubate to drink, and perform an adenomaly X-ray with a slight reduction on neoperitoneum, but we ordered even a CT scan. This is the real CT scan of the patient. We didn't found any kind of leakage, no leakage absolutely from the bowel. There was a reduction in neoperitoneum, but a slight increase of fluid in the pelvis. So, the patient was still feeling not well. She has no complete scene of perforation, but we decide to puncture the abdomen to catch an exploratory drainage of that fluid that unfortunately came out to be compatible with the entire material. So, what to do now? We did an X-lab, because of course, we have no evidence of the site of the leakage, but for sure there was a leakage. And we found a millimetric ileal lesion in the middle of the belly. It was below one centimeter. We explored all the cavity, all the ileal, all the helium, and that's the only thing we got. So, we did toilet, and the GI surgeon opted to do ileal lateral anastomosis with a staple. The patient recovered well and went home. Finally, I'm going to show you this case, because not all the complications are the same. It's not just about perforation, but we have also other kinds of complications related to the bowel. A six-year-old lady, very thin, she had a relapsed ovarian cancer. She went on laparotomic central recital reduction with a sigma rectal resection that was sutured with a mechanical end-to-end anastomic with a staple. The anastomosis was 10 centimeters far from the anus. So, we decided not to divert the patient, not to give her an ostomy. Also, after checking for the vitality, and of course, the next presentation will focus especially on how to check the vitality of the margins. On postoperative day three, she had a hemoglobin drop. We ordered a CT scan, and this is the CT scan, without contrast, because the patient also suffered from allergies, so we didn't give her the starting right. And what ended up to have a pelvic hematoma here of seven centimeter with bubbles inside. And it was exactly below the anastomosis, the rectal anastomosis we did. So, due to the drop, the hematoma, and the fact that it was air, we were suspicious of a tamponade perforation, we did the next lab. Abdominal toilet, no evidence of leakage of enteric material, no evidence of active bleeding outside in the abdomen. So, we did also an intraoperative rectoscopy. There was some dripping. The anastomosis was regular, was inflated, no leakage, so some cleaves were placed. The patient recovered well, and she went home on postoperative day seven. But, a week later, so on postoperative day 14, after site reduction, the patient completed fractal bleeding without having any kind of senior peritonitis, and she was at home. She came, and we did, of course, an exploration with a high suspicious of a lesion, but as I told, it was 10 centimeter far from the anus, so we ordered a rectoscopy, and that's the picture. We have the clips that were put one week ago, and there was a de-essence of the suture, of the circular suture stapler that was completely regular when we did the rectoscopy one week before. And of course, there was still some clot that blocked the exit of any enteric material. Of course, she underwent the next lab. There was fortunately no enteric material in the abdomen, but the abdomen was stuck. So we did that diverting colostomy. We didn't consider a suit for a direct anastomosis, and of course, we need also to put a VAC device to avoid compartmental syndrome because the patient was the third time in a couple of weeks that went to the OR. Just to sum up, some take-home message of bowel complication, and so not always free air in the head when it means having a perforation, but of course, and I want to know about the audience, how many of you will not have brought this patient to the OR? However, always think that a perforation may occur even if the incidence is very low for laparoscopic surgery is below 1%, and even if you don't have clear radiologic scene, you have to consider altogether clinics, but of course, and try to identify if there's something different, make a drainage, make a puncture, or whatever else, but of course, always think that it can happen to your patient, the patient you operated on, and identify this. And of course, among intestinal complication, always keep in mind that it's not just perforation. You can have bleeding of the anastomosis that can be outside the anastomosis or inside the anastomosis, even if it's performed with a mechanical device. Maybe you have some myelina for a resection performing in the lapar, some dropping of a bleeding that is not high, but of course, always think also about this and remember that the incidence may occur even if they are performing with the best technique, even if you check it with all the instruments you have and you're gonna see in the next presentation. Of course, there are also other complication may occur, but I think we are running out of time. At 10 minutes, they told me to talk, so I will go on and give space to the Q&A. Thank you for the attention. Thank you for that excellent presentation, Dr. Martinelli. Very interesting cases that you put forward, and I think your two points of, you know, if you, just like Dr. Lateo said, if you're going to operate, you're going to get complications, and that's a big thing to remember. And then secondly, these are variable presentation. You know, I think your, that first case with the free air on her X-ray doesn't always mean a leak, but then you also have a case where she had a leak, but no free air, so very interesting. You mentioned some criteria, or you mentioned that the anastomosis was at 10 centimeters, and then, and that was, for that reason you didn't divert that patient. Do you have criteria for which you would always divert a patient? Actually, we rarely divert patient, because we feel that, of course, quality of life and everything else very important for the kind of patient. Of course, we always discuss the case with the GIS surgeon, because we work in team when you do resection, and unless we are below the five centimeters and the tissue are not very vascularized, or as I think we have a presentation later on, on devices on how to evaluate the vitality of the anastomosis, we usually don't divert. Of course, if the lady's old, has comorbidities, has diabetes, the tissue are not well, we divert. And of course, when you go to the ER for an emergency surgeon, whether it's a peritonitis with a faecal material or something like this, we prefer to divert, because mainly we do the anastomosis, but we also do the protective ostomy to let the suture do, or the suture completely and avoid other problems, of course. Do you routinely bowel prep your patients? I know this is a controversial- This is one of the most controversial part. I am a fan of ERAS, but it's very difficult to discuss with the older colleagues that usually like to prepare bowel-prepared patients. So it's always a discussion. If we have, I'm suspicious of doing a resection with bowel-prepared patient to date, because also the GI surgeon prefer to have this. So we don't want to complain inside the ER about that. So true. But it's controversial, of course. Yes. So a couple of questions from the chat here. So when do you consider a direct repair and resection with respect to, or an anast- So when do you do a direct repair versus when do you do a resection and anastomosis when you have an injury with respect to size of the diameter of the bowel? Of course. Yeah, and it depends, of course. If the injury is intraoperative, you recognize it intraoperative, and the injuries is no more, if at least 30, 40% of the diameter, you can repair directly, of course. Even if it's completely open, you can just repair directly and put stitches without making a re-anastomosis. Depends on, it's case by case. There is no general rule. If you have a bowel that is completely stuck, you have to do maybe a couple of hour daily releases. it's better to put some stitches not to avoid any leakage during the procedure. And at the end, when we have all the bowels are thread, decide whether or not you perform a resection of some part or not to put stitches. Of course, the most important thing is, it's not the stricter, the lumen. ELL part will give you more availability and it's less complicated going towards the valve. The heliocircle valve, of course, increase the problems, but always try to make a suture, a transverse suture, not a longitudinal one, of course, but in case that there is a stricter, you recognize that there could be a problem of subocclusion or occlusion is better to resect. Great, and do you have a preference of staples over suture or suture over staples for those? So I'm not told, but when I started, we were used to do all by hand suturing. Terminal, terminal, something like this. Now we use a staple, but there is no general, or we can use the open one or the endoscopic one. Of course, technology is advancing. They only gives you a staple that is safer and safer. The most warning thing about the staple is just to check that there is no bleeding inside the lumen, especially if you do a helioresection, because otherwise you're going to recognize it like in the fifth or seventh day post-op when I start having myelina or something like this, and you wonder why the patient is bleeding or the hemoglobin is dropping. And of course, doing a procedure, an endoscopic procedure on a ileal area is more difficult than, as I saw on the rectal part when you can put the clips. So it's according to the device you have available, and I think the experience you have done, there is no difference in doing hand-sewed. There are the ones with one layer, two layers, single staple, double staple, tree line. It really depends on what you have available. On the type of tissues you have, of course, you have to know the staple you have, because not all the staple fits. There are different colors for different eight of the staples, so you have to be aware that a 3.5 millimeter is not good for a thick bowel and vice versa. Great. Well, thank you again for joining us this morning, and we're going to move on to our next speaker. Thank you. And next we have Dr. Taima May, who will be speaking with us about bowel complications as well. So thank you for joining us. Thank you very much for the invitation. So good morning. My name is Taima May. I'm a gynecologic oncologist at Princess Margaret Hospital in Toronto. And it's my pleasure to talk to you today about an asthmatic perfusion assessment and bowel perfusion assessment. These are my disclosures. The intraoperative use of ICG, endocyclic green fluorescence angiography has been shown to be safe and feasible. It's being used in multiple disease sites, including gynecologic tumors. The intraoperative use of ICGFA allows for objective assessment of bowel perfusion in real time. It identifies tissue with poor perfusion and can identify anastomosis at risk of failure. This can be used with other risk assessment strategies to help guide us for intraoperative decision-making and may decrease perioperative morbidity and amnestomotic leak. In this video, we see a patient who had a small bowel resection and currently undergoing a side-to-side small bowel re-anastomosis. So the GIA stapler is being used to create the anastomosis. The TA stapler is being used to close the anastomosis. And now the GIA staple line is reinforced. Following the TA staple line is imbricated and then the mesenteric defect is closed. After all this is done, the perfusion of the anastomosis is being assessed with the SpiFi handheld system after injecting endocyclic green. Endocyclic green is a dye with peak spectral absorption at 800 nanometers. Following intravenous injection, it binds plasma proteins and is confined to the vascular system. We usually inject three cc's of endocyclic green that's reconstituted with normal saline at a concentration of 2.5 milligrams per mil followed by 10 milliliters saline flush. The near-infrared frequency penetrates retinal layers allowing ICG and geography to image deep patterns of circulation. For sclerosal assessment of the bowel, often we can use portable handheld fluorescence imaging such as the SpiFi or the SpiQP. For mucosal assessment, so endoscopic assessment of the bowel, we often can use the pinpoint or the 1688. There are different modes that we can visualize the bowel in using the near-infrared platform. The overlay mode is the green mode. The contrast mode is the gray scale, white and gray. And the CSF mode is a scale that's graded between blue being less perfused to red being most perfused. In this video, after creating a side-to-side small bowel anastomosis, the patient received endocyanin green. As you can see, the bowel is green. And here with the CSF mode, there's similar perfusion of the anastomosis as compared to the bowel surrounding it. And again, with the green mode, there's no perfusion defects detected. In this video, we see a patient who underwent a large bowel resection. So had a low anterior resection with unblocked posterior pelvic resection. The anvil of the EEA stapler is being placed in the descending colon, which is the proximal limb of the anastomosis. And now the stapler is brought in through the anus and deployed in the distal limb. The circular anastomosis is now created using the stapler and the bowel continuity has been restored. So to assess the mucosal aspect of the anastomosis, we use the pinpoint system here after placing it in a sigmoidoscope sheath. And we can do an air leak test to ensure that it's negative. And then looking endoscopically, you can see after injecting ICG, there's green perfusion of the distal limb. You can see the circular anastomosis sort of at the top of the screen and then passing through the anastomosis. The proximal limb is also well perfused. Here we're using the newer platform, which is the 1688 4K platform. And you can see green perfusion with adequate intensity throughout. You can see the anastomosis there past the staplers. And then the distal limb similarly is well perfused with the overlay mode. We can also check with the contrast mode, which gives you a nice contrast between white and gray. And here you can see that there are no defects in the perfusion and the bowel is well perfused throughout the proximal and the distal limbs. So in some instances, it's quite obvious when we have ischemia on the bowel, as can be seen in the picture on the left where a patient who was actually referred with what was thought to be a small bowel obstruction and ended up being taken to the operating room with ischemic bowel. And the patient on the right had a previous surgery with resection of mesenteric tumor and had ischemia of the large bowel. These are obviously quite obvious. However, in some cases, the health of the bowel and the viability of the bowel is not clearly visible. And therefore it's helpful to identify and using the near infrared platform. Here, the patient had a side-to-side small bowel anastomosis. After injecting ICG, there's clear defect and uptake of endocyanin green at the distal end of the anastomosis. And this required revision of this anastomosis. This anastomosis appeared healthy when examining it with white light. After injecting ICG, you can see uptake in the majority of the anastomosis. However, there is one particular area that had a lack of uptake. And on further inspection, there's hypoperfusion of that area. And you can see it being blue with the light there. And then when we use the contrast mode, there's clear lack of uptake there of the anastomosis. And you can see how it is black with hypoperfusion. And this anastomosis was also revised prior to closure. Here, a patient had a low anterior resection with primary end-to-end circular anastomosis. And when inspecting the anastomosis, we can see that there's green uptake in the distal limb. There's adequate uptake in the majority of the proximal limb with the exception of the location. And this is a patient at seven o'clock that was hypoperfused and did not have any uptake, again, requiring attention. This is a patient that was referred with a uterine mass that was, as you could see here, the fundus of the uterus, the right adnexa, left adnexa, the descending colon there involved by the mass. And the mass was arising from the posterior aspect of the uterus and extending to the abdomen and the deep pelvis. This is a patient that was referred with the right adnexa, and you can see the specimen there on the left with the fundus, left adnexa, and the large uterine mass. When we inspected the descending colon, you can see a large mesenteric defect that was involved by the part of the mesentery that was involved by the tumor. As we all know, the inferior mesenteric artery comes from the aorta and then bifurcates into the left colic, the sigmoidal arteries, and the superior hemorrhoidal vessels, and they all collateral and create the marginal arteries of Drummond's, which are the terminal branches to the bowel. So we injected ICG to really examine whether there was compromise to the terminal branches and whether the marginal arteries of Drummond were intact. And as you can see, there was adequate perfusion throughout the colon with no compromise to any segment. Therefore, this patient did not require bowel resection. There have been advances in technology. The SPI-QP is the latest fluorescent assessment software that allows for additional analysis of bowel perfusion. The quantification piece allows for percent perfusion assessment of the target tissue, which often is your anastomosis or an area of bowel that you're concerned about in relation to reference tissue, which is usually a healthy piece of comparable bowels, either small bowel or large bowel, depending on the type of bowel you're examining as your target tissue. And it gives you a percent perfusion to sort of correlate in this healthy tissue, this is how much perfusion you would expect, and you'd expect similar values in your reference, in your target tissue compared to the reference. Color mapping shows increasing intensity of the fluorescent signal through a color map that identifies areas of differing perfusion, starting from blue being least perfused to green to yellow and to red being most perfused. This is how it usually looks. So the overlay mode is green, and you can see that in the picture on the left. In the middle, you can see color mapping, and this is a patient who had a low anterior resection. So you can see the bowel appears healthy, the vessels in the sidewall also appeared healthy. And then the adipose tissue is blue, meaning hypoperfused. The contrast mode allows you to see in white and gray scale, which is very helpful to see difference in stark contrast between well-perfused and hypoperfused bowel. So this is a patient who had a low anterior resection. You can see we injected endocyanin in green and inspecting using the QP software. So if you look at the bottom right corner of the screen, you can see the orange arrow there indicating that the system is now detecting endocyanin in green, and it's still increasing in the detection. Once there's maximum detection, the arrow turns green. So it tells you that maximum concentration is there. You can start the quantification and you check the percent perfusion of the reference bowel, and then moving to the anastomosis or the target area that you would like to examine, you can see the percent perfusion there. And again, looking at the proximal limb, there's adequate perfusion there. Again, with the color mapping mode, it appears red, which is helpful. Red for blood, meaning perfused. And when we compare it, for example, to the TA staple line beyond the stapler, there's hypoperfusion as expected, and the distal limb appears to be very well perfused as well. With contrast mode, we can see that there's no perfusion defects there. And again, the quantification is quite adequate in the proximal and the distal limb, which is quite reassuring. When we look at this patient who had a side-to-side anastomosis, again, we injected endocyanin green. And if you look at the bottom right corner of the screen, you can see the orange arrow indicating that there's recognition of endocyanin green in the vascular system. Once there's maximum perfusion detected, maximum concentration, the arrow turns green, and now we activate the quantification, and we can see the percent perfusion in the reference bowel there, ranging around 100%, and then moving to the anastomosis, where we'd expect the range to be comparable, and examining it with the color mapping mode, and again, with the contrast mode showing adequate perfusion throughout. There's no perfusion defects detected there in color either. In contrast, this is a patient who had a right hemicolectomy, and we're using this segment of the bowel to check for the reference range. So as you can see in the bottom right corner, the arrow is green, so there's maximum concentration of ICG detected. And when we check the reference bowel, it's around 100%, which is quite reassuring. And then moving to the anastomosis, there's a significant difference, where the range of the perfusion is about 30, 40, and 50% at maximum, and that was quite concerning, that this anastomosis, even though it looked anatomically normal with white light, it was quite hypo-perfused as compared to the surrounding bowel. Therefore, we decided to revise it, and immediately after the revision, the newly constructed anastomosis had excellent perfusion, comparable to the reference bowel. Lastly, this is a patient who had a tumor in the mesentery of the large bowel that was resected, and again, we wanted to inspect that the terminal blood supply to the bowel was not compromised. So as you can see, injecting ICG, you can see the bowel traveling, the contrast traveling through the mesentery vessels into the marginal arteries of drumming, and now we can inspect the perfusion and the quantification of the bowel, which was adequate throughout all segments of the bowel, and again, with the color mapping and the contrast mode, it was quite reassuring, and again, we were able to spare the bowel without needing to resect the segment of bowel. So in summary, perfusion assessment using ICG-FA is an innovative tool that allows for real-time, efficient, and reproducible assessment of bowel perfusion. Fluorescence angiography using ICG is a safe technique that can be used with other risk assessment strategies to aid intraoperatively and allow us to make intraoperative decision in patients undergoing bowel resection for gynecologic malignancies. Patients at increased risk of anastomotic failure can be identified intraoperatively, and the anastomosis may be revised. Thank you. Thank you, Dr. Mea, for sharing this terrific presentation. So let's open for discussion with the attendees, and I have a question. How long do you usually wait to make sure you gave enough time to have the perfusion? It looks like pretty quickly, but do you wait sometimes? How does it work? Most of these videos are in real time, so it is quite fast. Usually, we create the anastomosis, and in our practice, if it's a side-to-side anastomosis, we assess serosal assessment only, obviously, because if it's a side-to-side, we can't really look endoscopically. If it's an end-to-end, then we assess both serosa and mucosa. So we usually create the anastomosis. Within a few minutes, we inject ICG, and you really need to set up all the technology and the platform, because if you inject it, if the anesthesiologist injects endocyanin green intravenously peripherally, within 15 to 20 seconds, you see uptake. If it's centrally, it's usually five seconds, so it's very fast. We usually then do some interrupted sutures and imbricate the staple line and then set up for the endoscopic assessment. The washout period between injections needs to be about 10 minutes to allow for the next injection. Usually, it takes us about 10 minutes between two assessments. That was one of the questions I would do. And what's the dose you usually use for the first assessment? And dose for the second one, second time? Yes, so there have been some studies looking at two cc's versus three cc's. We usually use 3, 7.5 milligrams per injection. The maximum daily dose is two, I recommend is about two milligrams per kilogram. So for a thin patient of about 40 kilograms, that allows you to do at least 10 injections of three cc's each, which is usually way more than what you need for a debulking case. Great, and there are any factors that may jeopardize the function of the ITG? I mean, like hypoperfusion, hypothermia, or? Yeah, so absolutely. So hypothermia, hypoperfusion, intraoperative low blood pressure. So obviously with your anesthesia team, you want to make sure that the patient is hemodynamically stable and adequately resuscitated intraoperatively. There have been cases of link to iodine allergy. So patients with anaphylactic iodine allergy, we would not use it. ICG is excreted solely by biliary system. So it's not through the kidney. So usually patients with renal impairment that wouldn't impact their tolerability to ICG. It's very rare that we would not be able to use it or if it's contraindicated. Great, great. Well, unfortunately we don't have much time. So thank you so much. It was a wonderful presentation. And I would like to invite Dr. Newton Caetano da Rosa to show his video about gyne on complications in Africa. Good morning, everyone. Thank you, the organization for the invitation. I'm going to share my screen. My name is Nilton Caetano da Rosa. I'm a social oncologist on the Angola National Cancer Institute. I'm about to talk about gynecology, oncology complications in Africa. I'm not going to disclose for this presentation. In Africa, solutions for management of cancer needs to be sustainable, local, and reality-based. Because around 16 million people die from conditions that require surgical care in low-income countries. Establishing cancer units in our countries is not easy because we need healthcares that are capable of managing patients according to good standards of practice. That is quite difficult because we got low hospitals, volumes, procedures. We don't have so much data about surgical outcomes. The studies that dominate this activity generally are from high-income countries. And quite a few African countries have national registries and outpatient systems. For gynecology cancer, we also have a lack of training, especially that contributes with poor patient outcomes. The African surgical outcome study concludes that patients receiving surgery in Africa normally are younger than global average with lower risk. But yes, they are twice likely to die. One in five patients will have a complication and one to 10 will die from surgical procedure. When I speak about gynecology cancers, in Africa, cervical cancer is the number one in incidence and mortality, followed by ovary and uterus cancer. In Angola, according to the global plan, it's the same. Cervical cancer surpasses breast cancer, actually. Then we have ovary cancer and uterus cancer. We got a hospital-based cancer registry in Rwanda from the National Cancer Institute. It's quite similar to the global plan. It's from 2012 to 2016. And we have number one breast cancer. Actually, this is different, but we are updating this data. Cervical cancer comes first, then uterus cancer, and ovary cancer. From this group of patients, it's important to tell that most of the patients are stage three patients. Younger patients, but stage three patients. So we don't operate as much as we want to because they are local advanced patients. Something that we prefer to do is patient selection. We select very, very well our patients, I think. Because we have a barrier, like a religion barrier, and a lack of awareness of our society about cancer. In perioperative intervention, we talk to the family. We optimize patient requests. It's quite difficult because we don't have a system that interlinks our hospitals. So it's quite difficult to manage a patient with hypertension or diabetes. We usually don't do a mechanical bowel preparation. First thing we used to do that. And of course, surgical checklist like WHO recommends and antebrial prophylaxis. Postoperative interventions, normally we do prophylaxis for thromboembolism only 15 days. We followed the Arizona recommendation for postoperative flow therapy, perioperative nutritional care, and prevention of ileus. We use shrimp gum because it's cheaper. And urinary drainage only for five days because we used to have a lot of infection associated with it. And of course, early mobilization. So from 2012-2016, 33% of the surgeries were basically ovary cancer, followed by uterine cancer and cervix cancer. All procedures were open. Laparoscopy is something new in our service. We just acquired some equipment, so we don't have data on that. Upper abdominal bulking is something we don't do because ICU unit is new in our service. So we got a time for surgery, about five hours for patient. So we don't extend too much time of surgery because of the outcome, postoperative outcome. Lymphadenectomy for ovary cancer, we don't do because of some trials that we can use to justify. Usually the length of stay is five days. And we got three cases of that in 30 days of follow-up. This patient was with endometrial cancer. The two patients with endometrial cancer had a stroke on five days of staying in the hospital. So I'd like to thank the organization once more. This is all I have to share with you guys. Thank you. Thank you, Dr. Catano-DeRosa. Different, very interesting and different perspective. I will open it up for any questions that people might have. None. Dr. Ribeiro, did you have any questions? Yes. So Newton, you have had some training in Brazil, right? So how do you feel about the differences? You've been in a sicko-mite, which is a big cancer center. They have all the resources and all the best equipments we have. Do you feel like you have a better understanding of the equipments we have? Do you feel like your training was sufficient to work in Africa? Do you feel that you need some extra training or different setting or be prepared for different situations? How did you face that? I think as a sicko-mite, I was well trained for surgical complexities. But the difference between being at a sicko-mite and being in Angola is we don't have too much resources. So the perspective that I have treating a patient in Brazil was changing five years since I came back. For example, ovary cancer in a sicko-mite, we do a lot of resection, peritonectomy. The first patient I tried to do this here in Angola, he died. Because the support system doesn't work. We got a few training people that can help. So actually, we are training some people now in Brazil at INCA to change the perspective and the care of our patients. But at the beginning, this was the main difference. At the sicko-mite, for example, Dr. Mariana can help with vascular resection, etc. In Angola, this patient will be operated because we can't afford the complication. We have the resources to take care of that. So that's the main difference. That's interesting. Different realities. I think we can move forward. Do you have more questions? And how about chemo in Africa now? Do you have access to all the drugs and how does it work? Yes, we have radiotherapy and chemotherapy as well. One thing, the problem with chemo and radiotherapy is the time to begin the treatment. Actually, we have from the diagnosis to start the treatment is about 60 to 70 days for chemotherapy and about 100 days for radiotherapy. That's why, because 66 of our patients are stage 3, like I said. But there's something we're about to change because we pretend to operate more. So we're going to change some protocol. Something we discuss is post-surgical cancer, for example, is doing neuroadjuvant treatment because we don't have radiotherapy for all the patients. So we're going to start to do chemo, neuroadjuvant chemo, then operate. But we are discussing this. It's interesting. So Dr. Langstroth, should we? Unfortunately, it's a great session. I'm so pleased to have listened to you all. Dr. Langstroth. Yeah, I just want to share my thanks to all of our presenters and thanks to Dr. Rivera for planning this and putting this on. And then finally, just a reminder that you are all invited to IGCS in Korea. It'll be November 5th through 7th, 2023. And we look forward to seeing you all there. Thank you again to our presenters and thank you all for joining us this morning or afternoon, depending on your time zone.

gynecologic oncology

bowel complications

bleeding control

gas embolism

vascular resection

grafts

vascular complications

patient selection

ICG fluorescence angiography

cancer management

limited resources

chemotherapy

patient care