Well, I think we're we're on time and we're gonna go ahead and get started. So welcome everyone For those of you. I don't know. My name is Vance broach, and I'm a gynecologic oncologist at Memorial Sun Kettering Cancer Center as Head of the IGCS Education Committee Surgical Work Group and today's moderator I'd like to welcome you to the first ever IGCS film festival in partnership with the AGL Our film festival today is a virtual full house and we're joined by our maximum capacity of 500 attendees from over 80 countries around the world and Today's particularly uncertain environment We know there are many demands of your time and attention and we trust you'll find tremendous value in today's session. I Want to mention a few housekeeping items relevant to the zoom platform we're using for the festival To best view today's films, please adjust your monitors to full screen mode and the top right corner of your screen And adjust your view settings to fit to window Also the quality and clarity of the video presentations are contingent on the speed of your internet connection High speed and wired connections are best for viewing these videos If your video stream is of lower quality during our presentation today this webinar and all the videos Presented will be available to view on the IGCS education portal For additional video content IGCS has two excellent resources available to its members First the IGCS has partnered with the AGL to provide educational videos on the surgery you platform There are many excellent videos on this platform already available to you And if you'd like to submit a film for presentation to surgery you we would certainly welcome your submissions also, the International Journal of gynecologic cancer publishes surgical videos and the journals editor for these videos is professor Louie Shiva who's one of our presenters today? Videos can be submitted to the journal for publication and I believe you'll be discussing this later on in his talk as well Before we start today's session on surgical management of patients with ovarian cancer I want to remind everyone that today is world ovarian cancer day I'd like to acknowledge the women living with ovarian cancer the women we've sadly lost Their families and support systems patient advocates and all of you our IGCS members who take care of ovarian cancer patients each and every day I'm thrilled we're able to provide today's surgical film festival on ovarian cancer as part of the IGCS mission by sharing knowledge We strive to ensure all women affected by ovarian cancer have access to quality health care and a better opportunity for survival I'd also like to acknowledge the hard work and dedication of my colleagues in the IGCS They are an outstandingly talented and dedicated team who've been the backbone of this film festival and all of the educational content brought to you by the IGCS I'd like to especially thank the leaders of the education committee And I'd like to also highlight Mary Eichen, the CEO of IGCS, Debbie Leopold in charge of communications on our website And finally, but certainly not least Mandy Hansen who manages our online education and pretty much single-handedly is responsible for the production of this festival We have an incredible panel of surgeons today who will be sharing their expertise regarding the management of women with ovarian cancer Immediately following each film there will be time for discussion We encourage you to submit questions for our panelists via the live Q&A feature at the bottom of your screen We'll do our best to address as many questions as possible. If time allows, we'll also field questions at the conclusion of our webinar Now it's my honor to introduce today's speakers Joining us are Cara Long Roche from Memorial Sun Kettering Cancer Center in the United States Professor Luis Shiva from Clinica Universidad de Navarra in Spain, Rattan Ribeiro from Erasto Gairdner Hospital in Brazil Oliver Zivanovic from Memorial Sun Kettering Cancer Center in the United States and Alejandro Rauhain from the University of Texas MD Anderson Cancer Center in the United States And with that introduction, we'll begin with Dr. Long who will be discussing management of the newly diagnosed patient Who do we take to the OR for primary to bulking surgery? Dr. Long? Thank you, Vance Dr. Roche, I would just like to say a formal thank you to the IGCS team and Dr. Roche for organizing this It is truly an honor to be included. Today, I'm going to be speaking on the management of the newly diagnosed patient Who do we take to the operating room for primary to bulking surgery? Go ahead and advance. I have no conflicts of interest. Next slide. So ovarian cancer affects approximately 1.5% of the general population. As we all know, this risk is significantly higher in patients with genetic mutations and family history of the disease. There are no symptoms of early-stage disease. There is unfortunately still no screening test in 2020 and therefore the majority of patients will present with advanced stage disease and ovarian cancer remains the most lethal gynecologic malignancy. Next slide. Next slide. Primary treatment used to be simple, to bulking surgery followed by platinum taxing chemotherapy. However, in the modern era, next slide, things have gotten more complicated. The goal of debulking surgery is now the complete gross resection of all visible disease in the abdomen, pelvis, and sometimes chest. Chemotherapy can now be given in the neoadjuvant or the adjuvant setting. Targeted agents such as Bevacizumab have added to our regimen and we now have effective maintenance strategies such as PARP inhibitors. Next slide. The long-standing debate of neoadjuvant chemotherapy versus primary debulking surgery has yet to be rectified. Four major randomized control trials have demonstrated comparable survival outcomes between neoadjuvant chemotherapy and PDS and are commonly cited as the rationale for the increasing use of neoadjuvant chemotherapy. The overall survivals reported in these trials are 22 to 49 months in all arms. However, fierce advocates for primary debulking surgery continue to cite multiple retrospective studies, as well as prospective studies, which consistently report the longest survival outcomes in patients undergoing debulking surgery with complete gross resection of disease. You can see here results from GOG 172 and a retrospective study from our institution showing overall survivals of 78 months. So this data justifies the continued use of primary debulking in the properly selected patient. Next slide. So likely these improved survival outcomes are a result of proper patient selection and surgical effort and expertise. We've recently faced the additional challenge of resource availability during the COVID-19 pandemic in determining which patients are appropriate for primary debulking surgery. Patient preferences should always be incorporated into our decision making. But the two main factors that were left to balance are disease resectability and patient fitness. These factors cannot be evaluated in a vacuum as they are inherently linked. The more complicated the disease resection, the more fit the patient needs to be and there are no universally agreed upon criteria. Next slide. So at Memorial Sloan Kettering, we start by asking the question, is the patient fit for surgery? We consider consider factors such as medical comorbidities, performance status, age, recent venous thromboembolism, which is common in our patient population. And we use these criterias, which were published by the Mayo Clinic in 2011, which identify a patient group with a significant risk of morbidity in the first year of their life. Which identify a patient group with a significant risk of morbidity with PDS and likely no survival benefit. So if patients meet all three of the following criteria, age greater than 75, ASA greater or equal to three, or serum albumin less than three, and disease stage four or extensive surgery anticipated, we triage these patients directly to neoadjuvant. However, if patient is deemed an appropriate candidate for an attempted surgery, we then proceed to the MSK resectability assessment. Next slide. We have incorporated this multi-modality resectability assessment into our routine care. This resectability tool incorporates three major components. Clinical criteria, radiologic findings, and selective diagnostic laparoscopy. Next slide. We've previously published that in patients with a low resectability score, the rate of suboptimal debulking is quite low. So patients who are determined to have a low resectability score are triaged directly to an open procedure with laparotomy. On the contrary, patients with a high resectability score of seven or more have been reported to have a rate of suboptimal debulking of 50% or greater. These patients are triaged to diagnostic laparoscopy. Next slide. Next slide. The point of this triage approach is to offer surgery to the most patients possible while selectively utilizing our resource of laparoscopy and avoiding futile laparotomy in every potential patient. Next slide. Next slide. We've worked very hard in collaboration with our radiologists at our institution to develop these specific resectability assessment criteria to help guide us in our decision making process. The next few slides are to review the components of the resectability score. Each of these slides has examples of the disease locations of interest. On the left hand side of the slide represent disease sites that are easier to resect. And on the right hand side represent disease sites that are harder. Can you go back one slide, Vance? So here we see on the left, superdiaphragmatic lymph nodes and inguinal lymph nodes, which are easy to resect. In the middle, pleural disease, which is harder. And on the left, supraclavicular and pulmonary metastasis, which we deem unresectable. Next slide. Similarly, here we see perihepatic disease with subphrenic and capsular implants on the left, which we deem resectable. Intersegmental fissure and subcapsular implants, which can be difficult but resectable. And on the right, more dense portohepatic disease and parenchymal mets, which in some cases are deemed unresectable. Here we see left upper quadrant disease with splenic capsular implants and hyaluronic disease on the left. And on the right, more difficult disease, gastrocolic ligament and lesser sac implants. Next slide. Mesenteric disease is a frequently encountered reason for suboptimal debulking. On the left, we see suboptimal debulking, which we deem unresectable. And on the right, more difficult disease, gastrocolic ligament and lesser sac implants. Next slide. Mesenteric disease is a frequently encountered reason for suboptimal debulking. On the right, we see a nodular pattern, which in some cases can be resected. In the middle, an infiltrated pattern. And on the right, a retractable pattern, which in many cases is unresectable. Next slide. Here we see balsarosal involvement. Similarly, easier on the left, but with multifocal and gastric infiltration and extensive colonic infiltration becomes more difficult. Next slide. And finally, we have abdominal and pelvic lymphadenopathy. Easier to resect disease on the left, with pelvic and infarenal retroperitoneal lymphadenopathy, and moving towards the right, with more difficult to resect disease in the retrocrural and suprarenal retroperitoneal lymph nodes. We were scheduled to present the results of this resectability algorithm at the SGO annual meeting in Toronto, but unfortunately, that had to be canceled. But using this resectability algorithm, we have reported excellent surgical outcomes with over 75% rate of complete course resection, a 94% rate of optimal resection, a modest utilization of our resource of diagnostic laparoscopy at 26% of the total. And only a 6% rate of futile laparotomy. This demonstrates the algorithm with the additional component of how we manage moderate to large pleural effusions. These patients are taken for a VATS procedure to evaluate the pleural surfaces to deem whether a complete course resection is possible. And as you can see here, in these short video clips, go ahead and start them, Dr. Burge. These video clips are going to demonstrate two different diagnostic laparoscopies. The first patient had a very high resectability score. She was an excellent candidate for a surgical procedure medically. However, her resectability score was greater than 7, and we took her to the operating room for a diagnostic laparoscopy. In the operating room, we found extensive carcinomatosis in the abdomen and pelvis, with confluent plaques on the pelvic peritoneum, covering the entire cul-de-sac, as well as a densely infiltrated omental cake. And most notably in this patient, we saw a significant amount of small bowel cirrhosal disease and small bowel mesenterities. This patient, unfortunately, was deemed unresectable. She only had two ports placed during this laparoscopy, so she was able to go home the same day and went on to receive neoadjuvant chemotherapy and return to the operating room after three cycles for an interval debulking procedure. Hopefully you can see in the video here, the confluent disease plaques, which are extending from the mesentery to the cirrhosal mesenteric junction. This second patient came into the operating room with a very similar situation. She was also medically fit for surgery and also had a high resectability score. However, as you can see, despite there being a high volume of tumor, the small bowel cirrhosa and mesentery is clear. This patient was deemed resectable, and I've just included a short clip of the resection of her right upper quadrant disease. That second patient did undergo a primary debulking surgery and a complete gross resection was achieved. She had an en bloc resection of her right upper quadrant disease, which you could see was quite bulky on that laparoscopy. To summarize, we use this multi-modality approach. I think the most important component of it is collaboration with our colleagues in radiology to really utilize preoperative CT as well as possible to then triage patients to either a laparoscopy or a laparotomy in the management of their advanced ovarian cancer. I thank you very much for your attention, and I certainly appreciate the opportunity to be invited in this excellent panel. I'm happy to take any questions. Dr. Long, that was an absolutely amazing presentation and a spectacular video. Thank you so much for sharing that. While we're fielding some questions from our participants, let me just start by asking you, what are some of the things that you find when you look in on laparoscopy where you say, no, we're just not going to be able to do this one? What are the maybe one or two things that limit your ability to get a complete gross resection in patients who you bring for a primary debulking surgery? I think it's important really to look at both the CT findings and the laparoscopic findings together. Laparoscopy, as everyone knows, has its limitations. Very often these patients have a large omental cake, and you cannot get to some of the areas which can lead to the most challenging aspects of the subsequent debulking procedure. But certainly when we take patients for laparoscopy, I think the small bowel cirrhosis and the small bowel mesentery are two areas where the laparoscopic assessment can really add to the information that you've already gleaned from the CT. We have one question from the audience who asks, when doing a laparoscopy to evaluate for resectability, do you keep your ports in the midline in case of later port-site metastasis, or do you place lateral ports also? And do you see many port-site metastases after this procedure if you don't proceed with the debulking? That's a fantastic question. I use an open technique with laparoscopy, and so we'll use the Hassan technique. And I do always put that port in the midline using a small vertical incision for exactly that reason. Occasionally we will put the second smaller five millimeter port laterally. However, a midline approach is reasonable too. Okay. Port-site mets I find are not that common. I think in low-grade disease, we see them more often. But it's certainly something to keep in mind. Okay, great. One other question that came from the audience. How do you use the Fugate score in your practice, or is that something that you incorporate? Yeah, this is an ongoing area of exploration here at our institution. We have collected the Fugate score, and we have evaluated it in our patient population. We really have not incorporated it in a formal way. We have sort of utilized this triage algorithm using our receptability score that we put together and published. That is certainly another wonderful tool. One thing that I didn't mention is anytime we do a laparoscopy and deem a patient un-receptable, we do have a policy of calling in one of our colleagues, if one is available, to sort of offer a second opinion to make sure that both surgeons agree that the patient is un-receptable at the time of laparoscopy. Gotcha. Okay, well, I mean, we could talk about this for another couple of hours, but in the interest of time, I think we're going to move on. Thank you so, so much again for an amazing presentation. Thank you so much. Wonderful. Okay, so our next presenter is Professor Luis Shiva from Clinica Universidad de Navarra in Spain. And before Professor Shiva starts, I just want to just make a note, we have an outstanding attendance in this meeting, and it's wonderful. And with everybody jumping on, it's a little bit overwhelming, the Zoom system. So as people continue to jump on, there may be a little bit of delay in the advancing of the slides or in the playing of the video. And that will, as our kind of numbers settle out, that'll clear up, but I just wanna make you aware of that and apologize for the little bit of a delay in the slides advancing. All right, so with that being said, we'd like to welcome Professor Shiva, and we'll be discussing modified posterior exoneration or a combined hysterectomy BSO with low anterior resection. Professor Shiva? Yeah, sure. No conflicts to disclose. Vance, thank you very much for this invitation. It's for me an amazing honor to be here. I love this topic. I've been trying to understand much better every day this surgical technique, and I think it's something completely necessary for every single gynecological colleague around the world, right? Because overall, we are pelvic surgeons, right? Next slide, please. I mean, we have been a witness of an amazing implementations and accomplishments in ovarian cancer surgery during the last 30 years. And now we understand perfectly that the complete cytoreduction, R0, is our goal. And we can push survivors, you know, when obtaining this type of cytoreduction, right? So for doing this, it's completely necessary, I mean, we, as ovarian cancer surgeons, to master, you know, all the areas of the abdomen, the upper abdomen, of course, the mid-abdomen, the retroperitoneum. But overall, we have, you know, to be able to remove this type of tumors that are feeling in many occasions in the pelvis, and for years, have been considered unresectable. And this is one of my, you know, message to take home. Next, please. That, you know, is completely necessary. May I have my next slide? Ah, exactly. You know, the colorectal resection is really an indispensable maneuver to, in many occasions, to obtain a complete cytoreduction. So any gynecologist should master this technique. And we have, you know, to get training, right? And following, and with no complications. And most of the times, avoiding, you know, an stoma. My next slide, please. So, I mean, I want to tell you, and this is my experience for the last, you know, decades, that we can state that most of the disease can be resected in the pelvis, right? But there is nothing in the pelvis, I mean, talking about ovarian cancer, that is unresectable. And in many occasions, we can avoid an stoma. Okay, I remember this patient. This is a patient that I operated, you know, 10, 12 years ago, and she was alive for, I mean, I would say more than 10 years, right? And she was not brachymotated. So in the literature, it's important, you know, to highlight that most of the series of ovarian cancer show a rate of colorectal resection of almost 30%. So if in our series, we have, you know, lower numbers, we have to consider seriously that probably we are not doing, you know, the right surgery. And what about the stoma? I mean, there is no point, you know, to perform a colorectal resection, even in each case, the stoma. On the literature, we have, you know, an average rate of 13% of stomas with a very low fistula. So I think in conclusion, I would like to say before watching the movie, that this is a crucial maneuver that we have to master. And we have, you know, to take time. We are pelvic surgeons. We are ovarian cancer surgeons. And most of us, we have to do this surgery in a safe way, right? With low rates of complications and minimizing the rates of stoma placement. So to finish before showing the movie, I want to remember, you know, I have the honor of serve as video editor of our journal. And I would love, you know, you to send us, to submit us, you know, any video that might be interesting to the international community and can impact, right, in our training. So let's see the movie that I have prepared to you. I mean, it was a 73 years old female with a history of a frozen pelvis and the diagnosis of endometriate, rate three endometriate carcinoma of the ovary that was filling the pelvis, that was eroding the posterior aspect of the vagina. The patient, I mean, was coming to the hospital complaining of bleeding. She had disease in the retroperitoneal area, a bulky tumor in the pelvis and infiltration of the rectum. So as always, you know, huge incision for doing these surgeries. I love the Thompson retractor. I want to be sure that I can, you know, remove all the disease. And as always entering the pelvis, I want, you know, to dissect my landmarks and my ureter in the right side. I'm cutting right now, the right in front of the ligament, opening the spaces, separating the peritoneum. I have to remove in this case of frozen pelvis, the whole peritoneum along with my specimen and to be sure, you know, what is my ureter. Cutting in this case, the right round ligament. And now I'm dissecting the right ureter, opening the pararectal and the paraversical space. And I was a little bit uncomfortable in this case because, you know, the tumor was really filling the pelvis, right? So I am opening the spaces, but in most of the cases, the tumor is not infiltrating the pelvis side wall. Now on the left side, on the left side, I'm placing my vessel loop in the left ureter. And afterwards, again, I'm going to cut the left in front of the ureter. Here we go. I usually love to use, you know, ligature, but you can do whatever you want with these pedicles, right? So now on the right side, I'm ligating, I'm dissecting the right uterine artery, again, with ligature. And, but I'm going to tell you something. In the left side, I make a clear mistake because I'm cutting here. And I want, you know, to be humble and to say in this, I'm cutting here the left ureter. It's something that happened really very infrequently, but they were so confident in me that they didn't want, you know, to dissect the whole ureter. I thought that it was the left uterine artery, but it was the ureter. And I had to repair afterwards, right? So now I have opened the anterior aspect of my, of the vagina. I'm pulling with the tenaculum forces from the cervix. I can start to see the metastasis of the vagina. And now I'm dividing the rectal sigmoid with my linear staple device. And I'm going to cut and to divide the sigmoid vessels to getting what is called the holy plane, the pre-sacral plane. That is, you know, a very, should be a very well-known plane for the pelvic surgery, right? So now I'm getting down deeper in the pelvis, cutting, you know, part of the mesorectum and probably part of the utero sacrum as well on the pre-sacral ligaments. And now I think I have in my hand the whole specimen. So after, now I'm working in the rectovaginal space. I'm pulling from the cervix with the tenaculum forces. And little by little, I'm dividing the mesorectum in order to freeze the whole, you know, rectum below the disease, little by little, defining where is located the mesorectum and avoiding, you know, to harm the bowel, right? So once the bowel is completely clean and I'm sure that I'm not going to have a positive margin, I can introduce my contour, in this case, device in order to, this curve staple device, that is, I love it. And I've been using for years, that give us the opportunity of placing staples in both sides, in both sides, without, you know, spreading the fecal content and can give us, you know, a very clear cut, as you can see here. So this is the specimen, it was an endometrioid. In fact, it was an endometrioid tumor with different aspects, histologically speaking, with grade one, grade two, grade three. This is the vagina that was eroded, that was infiltrated. And the rectal stump, right? And the line of staples, right? This is really an important surgical maneuver to become a real ovarian cancer surgeon, right? I love, you know, to see the specimen and as you can see here, it was completely indicated, right? So, well, now this is, unfortunately, my ureter that was cut and I had, you know, to reconstruct afterwards. And just a small tip, I love, you know, to close the vagina. I don't want to have any vaginal dehiscence opening after the surgery, so I love to close the vaginal cuff very carefully with just, and closing, you know, with some interrupter sutures as well. Now I'm removing some, you know, bulky nodes in the pre-aortic area and in the inter-aortic area. And finally, in this case, I have, you know, to cut the inferior mesenteric artery for many reasons. But first, you know, to make an important debulking in this para-aortic area, as you can see here. So I almost done, just below the left renal vein. And now I have removed almost all the disease in the right para-aortic area. Just some more nodes, positive, of course, in this bulky, you know, tumor. And then just removing the last nodes between in the inter-aortic area, right? The patient had some metastasis in the splenic ilium. I'm, in this very moment, just dissecting and cutting the splenic artery alone in block with the omentum, right? Here we go. Yes, the last attachments of the spleen. And now on the right side, if I remember well, I had, you know, some tumors over the right diaphragm. And I had, you know, to remove a plaque in block of the, not only stripping, but also removing, you know, the part of the diaphragm in block. And then I had, you know, a bulky tumor over the gerontas fascia, over the right kidney, right? Here we go. That's the, sorry, the right kidney, exactly. So let's go to the pelvis again, right? So the first movement is, you know, to be completely sure, completely sure that I don't want to have any tension. But remember, I have cut the inferior mesenteric artery. So it's really key, you know, first to mobilize very nicely, you know, my rectum, my decimoid colon, but to preserve the archaea. If I, you know, injure the archaea, it's going to be a huge disaster. So I have to do everything from the left parietocolic gout here, little by little, removing the attachments, but preserving carefully my archaea. Otherwise I'm going to suffer a lot, okay? So now I think that, you know, I have mobilized enough my, the colon, and I'm going to do my pulsar string, right? I love, you know, this device. It can be done manually, but with this pulsar string device, I can place, you know, my suture surrounding the lower stump of the sigmoid. And now with my forces, I dilate a little bit, you know, the opening of the left colon, and I'm going to introduce the umbil, a trick here. A trick here is to use a little amount of jelly, right? To introduce my umbil, and I'm going to close the suture surrounding the umbil carefully, gently. And I want finally to clean up all the fat that is in the serosa, because from the times of Bill Roth, we know that the best way, you know, of avoiding any complication is, you know, to clean perfectly the serosa. So here we go. Now my assistant, I'm cleaning up the pelvis again. And my assistant is pushing the endoanal circular trochar through the stelpinland. Usually I prefer, you know, to go either above or below the stelpinland, carefully pushing, you know, the trochar. And now avoiding any twisting of the mesentery, I'm going to adapt to introduce the umbil into the trochar, and I'm going to fire my device, I mean, my assistant from below. This should be done carefully, gently, with no, you know, harsh movements. And because, you know, it's a disaster to have in these patients a leakage afterwards. So no tension at all. And I want to be sure by filling my anastomosis with methylene blue, with that is, you know, completely watertightness, you see. And even though most of the general surgeons, they don't over suture the anastomosis, I love to do it with interrupter sutures, 3-0, bicryl, at least to eight sutures approximately. And I sleep much, you know, quietly. And let me tell you my rate of, I have done probably this surgical approach in 300 times, and my leakage rate is less than 3% or 2%. So I feel really comfortable with my suture, with my anastomosis, and now this is another surgical procedure that I love very much, right? Which is the ureteral vesicle anastomosis. First, spatulation. We want to have, you know, a wide contact between the ureter and the bladder. And I use for this, the potter spot, the potter spot. It's a scissor, sorry. And for some time, I used to open a huge, you know, opening in the bladder, but not anymore. I'm copying the urologist when they're doing a renal transplantation, and a small hole in the bladder. And I first place a suture in the angle of the spatulate ureter. And always, in every single case, I love, you know, to catheter my ureter with a 6F catheter, a pigtail catheter that I'm going to introduce in the bladder. And then afterwards, little by little, with interrupter five of bicryl sutures, I'm taking in the ureter, the whole wall, and in the bladder, only the mucosa and the submucosa, right? With avoiding always the tension between the ureter and the bladder, and being sure that there's water tightness as well. And I leave the catheter for a couple of weeks at least, right? And in this case, we can, you know, suture over the anastomosis, you know, the muscular, and even the adventitia of the bladder in order to somehow perform an antireflux right suture, as you can see here. So, and I love, if I can, to avoid tension by suturing the bladder to the psoas muscle as well. So this is the surgery, right? The patient was seven days in our hospital and she had no complications. Thank you very much for your attention. A pleasure. Well, that was an absolutely spectacular video. I think we can all agree. And, you know, it's just so wonderful to see what your technique is and how you approach that. Let me start by asking you a couple of questions actually from the audience. One audience member asked, do you, what do you find the role for bowel preparation to be? Do you use mechanical bowel preparation? Do you use antibiotics? And what do you do there? That is a key question. I mean, as you know, General Surgeons has abandoned or have abandoned the bowel prep. But, you know, I'm doing it in every single case because, you know, unfortunately, it's not, you know, unfortunately medicine-based evidence, but my rate of complication is so low. I hate to find a stool at the time of opening, you know, the bowel. And at least, I'm not very thorough right now, but, you know, at least an MS for sure. But if I can, I give, you know, preparation, bowel preparation. Yeah. Okay. This is, I mean, I want to say that too. I mean, what I'm doing. Yeah. Okay. And another question from the audience, at what point would you consider requesting a consultant to help you with the procedure? Do you typically do your ureteral anastomosis and your upper abdominal resections and your colon resections on your own? The colon resection and the reconstruction is, I've done, I mean, for many years, for almost 10 years, I had the great opportunity of operating with a General Surgeon. But, you know, after done, you know, dozens and dozens and dozens and, you know, I feel very comfortable and I do the whole thing by myself. Let me tell you something. I had, you know, a fellow, a former fellow that after finishing gynecology, he became General Surgeon and he's as well in my team. But, you know, in some occasions I'm operating alone. So I feel comfortable for doing both the anastomosis between the ureter and the bladder and the colorectal anastomosis as well. Okay. Excellent. Well, I think in the interest of time, we're going to move on. Thank you so much for the amazing video and the presentation. What an absolute treat for us. Thanks again. Thank you. Okay. So our next presenter is Professor Riton Ribeiro from Eraso Gartner Hospital in Brazil. And he's going to be presenting a video on a right diaphragm resection. Professor Ribeiro. Hello. Good morning. I'd like to thank the IGCS and the AGL for this opportunity. It's a great honor to join you today. So we can start the video. So I'm going to show you a very basic, say, procedure, trying to keep it very simple so you can join the discussion and make it in your daily practice. So these are my disclosures. Well, regarding the indications for the laparoscopic approach, we believe that almost anything can be done by MIS, But it doesn't mean you should do it, right? So due to the lack of data regarding the oncologic safety of the MIS for such patients, we prefer to use it for patients with limited diaphragmatic disease. So those are the typical cases we do laparoscopy, which are patients with a small burden of disease on the diaphragm. So you have to be absolutely convinced that you'll be able to perform the complete cytoreduction using the MIS approach. So regarding the anatomy, the vagus nerve is responsible for the motor innervation and it has fibers running on both surfaces of the diaphragm. So on the caudal surfaces, it emerges laterally to the vena cava foramen and its major branches run along the phrenic vein and artery branches. So the coronary ligament is at the anterior part of the liver and the triangular ligament is laterally and they keep the liver attached to the diaphragm. They also work as a barrier for the peritoneal implants and that's why you will not find implants in the bare area of the liver. The suprapathic veins in vena cava are just posterior to the medial part of the coronary ligament. So this is the regular position that we use for the pelvic part of the surgery regarding the trochars. They are not so useful for the diaphragm because it's so far from the diaphragm. So the left picture shows our trochar placements when a right diaphragm resection is combined with the pelvic procedure. But if there is disease on both sides of the diaphragm, we prefer to insert the trochars in the midline so you can use it for both sides. So usually the surgeon stands on the patient left side and using his right hand with the subsuphoid port and the assistant stands in between patient's legs, holding the camera and assisting with his left hand. This is a typical case for the laparoscopic approach. If you look closer, frequently you find disease all over its surface. So it's important to be sure you are getting all the disease. And for those patients with small implants, it's important to mark the area to be resected because during the procedure, the grasping of the tissue will create some artifacts that may cause confusion. For instance, you may not differentiate a tumor from a grasping area with a hematoma or something like this. So we prefer to use the harmonic or bipolar energy to do these marks and throughout the diaphragm take part of the surgery because they are much safer. You should avoid using monopolar energy because as you can see, it will cause contraction of the muscle and you may have complications as a pneumothorax. So if you decide to use it, usually the best way is grasping the peritoneum instead of pressing against it. But still be careful because you may have a complication like a pneumothorax or something like that. Well, the resection itself starts with the sectioning of the adhesions with the liver. Remember that these adhesions may have tumors, so it's important to resect them along the spacing. So it also will allow you to access the coronary ligament that's on one of our boundaries and it has to be incised to have proper liver mobilization. So remember that at this point, the suprapathic veins are entering the vena cava just a little to the right in posterior to the junction of the falciform and coronary ligaments. You don't have to dissect those vessels, you just have to know they are there unless you have tumor in this area. Well, here you can see the peritoneum is separate from medial to lateral from the muscle. This way the chance of perforation is less, especially at the tendinous part of the diaphragm where the peritoneum is firmly attached to the muscle or to the diaphragm. So you may use the active way to separate it from the muscle. As you get to the muscular part, the peritoneum normally is easily detached from the muscle, so that's not difficult. Again, you see the section of the coronary ligament and we like to use the harmonic to separate it from the tendinous part, as I said before. And you can do it by separating the peritoneum from the muscle using a combination of blunt dissection and energy, but sometimes more infiltrative lesions or post neoadjuvant fibrosis can be much more challenging. One interesting point is when you are getting closer to the phrenic vessels, you see in a couple of seconds, you have to be more careful not to coagulate too much or to damage the branches of the vagus nerve. So I suggest to use more blunt dissection and less energy to avoid damaging those branches. Like in this part of the video, you can see we are grasping the peritoneum and you can see the vessels just behind it. So avoiding coagulating those vessels unnecessarily, you have a better function after surgery and less paralysis of the diaphragm. Of course, if you have some bleeding, you coagulate it. To resect the posterior lateral part, the assistant can use a liver retractor to push the liver. It will provide access to the triangular ligament. And using traction of the peritoneum, this ligament can be sectioned and the peritoneal diaphragm resection is basically completed because under it, you just have the epithelial renal fossa to be resected. So you can see in this case that the phrenic vessels were coagulated and this patient had a temporary diaphragmatic paralysis because you have nerves on both sides of the diaphragm. So the thoracic part will compensate it. It's also important to keep those patients in postoperative physiotherapy because of it. So as the major ligaments are cut, you can use a liver retractor through the umbilical, through the subsulfoid part to resect the peritoneum under the liver. So this is the final aspect of the resection. You can achieve quite large resections using this approach. I'm going to show you a couple specimens. As you can see, sometimes they are 20 to 30 centimeters long resections. And usually combined with other resections. Here is just the most common transoperatory complication. You can see a small hole in the diaphragm. And you can just close it using an unobservable thick suture. If the lung is partially collapsed, it's possible to insert an IV candela through the thoracic wall, close the suture, and then aspirate the pineal thorax. If the lung is not collapsed before closing the suture, you can insert a nasogastric tube using your assistant trochanter and through the diaphragmatic defect, aspirate the pineal thorax and then tie the suture while removing the catheter. That's a good way to solve the problem. Obviously, if you have a large defect, it's much more difficult to keep the pineal peritoneum to perform the suture. So you may need conversion. But most of the diaphragmatic resections can be repaired primarily so you can do it. As you can see, this is a patient with fibrosis due to post neoadjuvant treatment. Symptomatic pleural effusion is the most common complication after upper abdominal resection. But it's very difficult to isolate the complications just related to the diaphragmatic resection. But obviously, in this case, this is a hernia. So it's related to this resection. It was a full thickness five centimeter lesion and she got a hernia. Well, in conclusion, I would say that it's a feasible procedure in selected case. Not so difficult if you have some expertise. Obviously, it has some complications, but nothing you cannot deal with. I think the most important thing is selecting the cases. And as you get more experience, you go for more difficult cases and so on. So again, thank you so much for the opportunity. That was an unbelievably beautiful video and such a great dissection. Thank you so much for presenting that. To start off the discussion, I'll field a question from the audience. An audience member asks, how can you be certain that you've inspected the entire diaphragm, particularly Morrison's pouch, if the liver isn't fully mobilized? And kind of add on to that, it seems like the right triangular ligament and the barrier area of the liver is a little bit more challenging to expose laparoscopically. So how do you approach that and what kind of tricks can you help us with? Yeah, I think that's the main question about the laparoscopic approach is how can you assure you have reached all the spaces and all the areas that you should evaluate and resect and wherever. So obviously this is an edited video. So during throughout the procedure, you have to be sure you have mobilized the full, all the liver and go around it. Obviously it's not something you can compare to open procedure where you can just put your hand in and move all the liver at once. So what we do, we do it by like small parts each different time. So we do all the anterior part, then we move to the posterior part to like taking up the liver, resecting the hepatorenal fossa and so on. So it takes a little time. You have to be a little bit annoying with their team and looking for disease, but obviously you have to select the case. That's why we don't do for bulky disease where you have to be, you have to be very confident that you can remove and evaluate all the abdomen unless if you don't are absolutely sure you should not do it. I think that's the point. Okay, great. A question from Dr. Boclaivi. Are you concerned when you open the diaphragm with the positive pressure of laparoscopy that you're causing plural dissemination of tumor cells or has that ever been investigated in any way? Well, that's a really good point. I don't remember a patient with like a thoracic recurrence without abdominal recurrence. After those kinds of surgeries. So I really don't feel like that's a major issue, but for sure it should, we should investigate it. In some cases, obviously you have, well, you have enamel peritoneum get into the thorax and you also have this fog from the harmonic or whatever, and you may have cells. But usually you don't have like liquid coming to the thorax or like something like that because the opening usually it's a bit higher. So the liquid, it's always on the bottle. So I'm not so worried about it, but obviously it can happen anyway. Even in open procedure, you put your hand inside sometimes or your finger and you pull through and you pull the diaphragm. So this kind of contamination can always happen. But I don't feel like that's a very important issue, but it's a good question. How frequently would you say you have to convert from a laparoscopic approach to an open approach either because of entry into the pleural cavity or because of disease involvement? I would say that like 10% of the cases we have to convert, but that's because we selected the cases for the laparoscopic approach. When there's a big burden of disease, we just convert the patient and we do it open. So I remember just a few cases of conversion, most of them because we didn't manage to keep the pineal peritoneum when we were resecting the diaphragm. That's all of them were because of that and not because of bulky disease. Because when we have bulky disease, we just go for open surgery. It's not something that you can do like, I want to try it. You must be sure you can do it. Gotcha. Okay. And another question from the audience, was this case a primary debulking surgery or an interval debulking? Well, there were like, I think, four or five different cases. So we mixed up them. But the main case was a primary cytoreduction. Yeah. Gotcha. A low-grade, serious low-grade tumor. Carcinova. Well, thank you so much again. That was an absolutely beautiful video and a wonderful discussion. With that, we're going to go ahead and move on to our next presenter, who is Oliver Zivanovic from Memorial Sloan Kettering Cancer Center in New York. And Dr. Zivanovic will be presenting a left upper quadrant dissection and portal hepatitis dissection. Dr. Zivanovic? Hi, Vance. Thank you so much. And thank you for the organizers. It's an amazing honor to be part of this panel and this great video session. So I'll be talking about the left upper quadrant. And one of the most important things when you're operating in the left upper quadrant, for me personally, is exposure. So it's really important if you're doing open surgeries, as we mostly do for our ovarian cancers, to use an incision up to the cyfoid process. There's multiple retractors. We at our institution use the Bookwalter. But there are certainly other retractors that are perfect for exposing and lifting the coastal margin, which is crucial for doing left upper quadrant surgery. The other thing that's really important is to be familiar with the anatomy, as with everything that we're doing, in order to avoid unnecessary damage or injuries, especially to the vasculature. And we can see the stomach is lifted up. And we're looking at the celiac trunk, which is a critical structure when we're operating in the left upper quadrant. From that celiac trunk, important vessels are originating, the left gastric artery, the splenic artery, and the common hepatic artery. And these are critical structures when we operate in the left upper quadrant. Again, here, we can see the celiac trunk a little bit better. The outflow, the inflow to the liver is important. The proper hepatic artery is then divided into the left and right hepatic artery. But there are some anatomic variations. And we can see them in the next slides. Oftentimes, the right hepatic artery is replaced by an accessory right hepatic artery, which actually arises from the superior mesenteric artery. We can see this on the left side of the screen. Then you'll find it, actually, in the porta hepatis. And it's important to know that this variation is very common. And on the right, can you go back one slide? On the right side, we can see the left hepatic artery arising from the left gastric artery. And I'll show you in the video later a variation that is very common. And then next slide, the anatomy of the liver divided up in segments. We can clearly see, and that's very important, the inflow of the liver provided by the portal vein, the hepatic artery, and the common bile duct. And we can find these structures, obviously, in the porta hepatis, the ligamentum hepato duodenale. And then we can see the outflow of the liver, which is the right hepatic vein, middle hepatic vein, and left hepatic vein, which are then flowing into the IBC. And it's important to know these structures as we're mobilizing the liver, both for the right and left upper quadrant. Okay, so for the left upper quadrant, when we lift up the left lobe of the liver, we're going to get into the space where oftentimes ovarian cancer is located. And we can see the ligamentum teres, which is an extension, actually, of the left portal vein. It's very important to know that because oftentimes tumor is found in the falciform ligament and then growing into the fissure of the ligamentum teres. And it's important to know that the ligamentum teres is an extension of the left portal vein and the distal branches of the left portal vein are close to the ligamentum teres and they have to be preserved when removing tumors from these structures. Then, can you go back? And then the other crucial structure is the ligamentum venosum. It connects the left portal vein with the left hepatic vein. And this is oftentimes, we'll see some tumors around the caudate lobe in this ligamentum venosum. And I'll show you in the video how it can be safely removed. But it's really critical to know these structures. And we've seen this picture before. This is the right and left diaphragm. And tumors from the left diaphragm are equally removed from the right diaphragm. The one difference is that their pericardium is close to the left diaphragm and needs to be watched. So what are the diaphragm, what are the pitfalls for left diaphragm resection? Obviously, injury to the left hepatic vein, phrenic nerve injuries. We've seen this in the video previously so well. And then splenic injury due to correction and injury to the pericardium because the pericardium is located quite close to the midline, to the inner quadrant of the left diaphragm. Okay, and here we'll see opening in the left diaphragm and we can see cardiophrenic lymph nodes that we sometimes have to remove because they're enlarged. We typically do the incision more lateral because as I've explained before, the pericardium you can see here is right there. Sometimes we have to go closer immediately and then here we can remove the lymph node and we'll see that it's really easy to injure the pericardium here. We're removing a lymph node from the cardiophrenic lymph node and we'll see, hopefully you'll see a little squirt of fluid coming out very soon. It's the pericardial fluid that's coming out of a hole from the pericardium. But this hole can be easily fixed. We have to expose this a little bit more after removing this and we can open up the diaphragm more and expose the anti-pericardium and just fix the pericardium. Next slide. And this is the sutures that are used to repair the pericardium. All right, and then for the splenectomy, I've learned a lot of ways of splenectomies. There's the anterior and posterior approach. Dr. Bill Clybee from the Mayo Clinic has shown me a very elegant posterior approach to the splenectomy. It really has changed the way I'm doing my splenectomy since I've seen his videos and I can only recommend everybody who has a chance to see Dr. Bill Clybee demonstrate the videos of the splenectomy, it's really beautiful. It's quite straightforward. We can see the splenic artery here on the surface on the upper boundary of the pancreas and the attachments are clear. The spleen is attached to the stomach with short gastric arteries and in the gastrosplenic ligament. And then to the diaphragm, as well as to the kidney and to the colon and all those attachments have to be taken so that the spleen is mobilized. And then there's a very elegant approach. Once you've mobilized the tail of the pancreas above the left kidney, there is a vascular plane behind below that and you can really mobilize the pancreas very nicely in this avascular plane and mobilize the entire spleen with it so elegantly that you can see the splenic artery and vein and ligate them posteriorly. And the next slide, you'll see this, next slide, please. Yeah, here you'll see the avascular plane and you can really connect and mobilize the pancreas, pancreatic tail all the way to the superior mesenteric vein. It allows for a nice mobilization of the spleen and a safe ligation of the splenic artery and vein. Okay, final steps, hemostasis, obviously some people prefer drains. There's not a 100% agreement. Some do it only if the pancreas was involved or if there was a little bit more bleeding. Some people consider antibiotics. There's really no clear guidelines. There's some very good studies that suggest that if the pancreas is involved to use a stereotype, this is a new England medical journal from Peter Allen who has done a randomized trial. With a splenectomy without a distal pancreatectomy, I usually don't use any drains. Obviously post-operatively, please don't forget the vaccinations to avoid post-splenectomy sepsis. Okay, and then I think we're gonna go to the surgical film. This is a surgical film. First, we're gonna see very quickly the ligamentum hepatoduodenale, the porta hepatis here with the pringle around it. So we're removing some lymph nodes from the lateral aspect of the porta hepatis. Careful dissection of the tissue is imperative here because the structures are clearly the common bile duct and below that the portal vein and carefully dissecting the tissue of these sometimes enlarged lymph nodes is imperative to preserve and avoid vascular injury to the portal vein as well as the common bile duct. Here with the finger, you can actually go through the foraminal vinslow and just dissect off those lymph nodes carefully, protecting the portal vein and the inflow into the liver. And here we're removing the lymph nodes with clips and the enlarged portal inflow lymph nodes are removed here without problems. In the next video, we'll demonstrate removal of tumor from the ligamentum teres. Here, the tumor is palpated and with the bovie encircled. It's really important to know that the ligamentum teres is the extension to the left portal vein as I explained a little bit earlier. And here the liver needs to be, the tissue needs to be clamped and crushed until we see the base of the ligamentum teres, including the tumor. It's important to preserve any major vessels into the segments three and four of the liver from the left portal vein. And we're doing this on the left side of the liver and also on the right side of the liver. And again, the idea is to really get to the base of the ligamentum teres. And the tissue in front is crushed and dissected free similarly to the other sides and the dissection is carried on until we can see the base of the ligamentum teres, which again is an extension of the left portal vein and we don't wanna injure that here. You can see the ligamentum teres nicely and you can free it and free some tissue and some smaller vessels from this ligament. And once this is freed along with the tumor, we can then safely staple this ligamentum teres. Before stapling, we have to make sure that the left lobe of the liver is well perfused and then there's no ischemic changes. Once this is done, we just use the stapler here, an endovascular, endo-GIA vascular stapler to remove this tumor and protect the terminal inflow of the left portal vein. Next video, we'll show you the resection of tumor from the ligamentum venosum. Here, the left lobe of the liver is retracted and we can see tumor below there along the ligamentum venosum and we have to mobilize the left lobe of the liver here by freeing the triangular left ligament. Here, we have to dissect free the left hepatic vein, which is crucial because the ligamentum venosum is inserting into the left hepatic vein and the tumor along the ligamentum venosum oftentimes inserts into the, or is close to the left hepatic vein. Here, we can see the left hepatic vein and the superior aspect of the caudate lobe, which is freed here. After doing this, we're opening up lateral to the porta hepatis and we can see the inferior aspect of the caudate lobe of the liver and we can see the tumor along. And here, I've explained before, here's a very nice example of an accessory left hepatic artery with the origin of the left gastric artery and we can preserve this. We're going to put in a vessel loop around the left gastric, a left accessory hepatic artery at the origin of the left gastric. And then we're dissecting free tumors. After doing the Pringle maneuver here, we can, we're dissecting the tumor of the left portal vein, which again is a very crucial structure to see here because the left portal vein is connected to the ligamentum venosum and we have to make sure that we see this left portal vein before we can free the tumor here of the left lobe of the liver. So now we're free, we have dissected free the left portal vein and we can now nicely free the tissue connected to the tumor from the left portal vein without injuring the left portal vein. After doing this, here you can see the left portal vein. And now we're trying to preserve the accessory left hepatic artery that I have explained to you a little bit earlier. We can do this by removing the tumor without sacrificing the accessory left hepatic artery. After doing this, the tumor is further mobilized superiorly to this. And now we have to turn our attention to the left hepatic vein. And we can see that we're doing this here. The left hepatic vein is right there and we're freeing tumor from the ligamentum venosum. And here's the ligamentum venosum actually inserting into the left hepatic vein. As explained before, this is crucial. It's an obliterated ligament and it can be safely cauterized off of the left hepatic vein. After doing that, downwards traction of the tumor from the left lobe of the liver. And now we're going again towards the left portal vein where the ligamentum venosum is attached to as well. And we're just freeing this tissue along with the tumor. And after doing this, everything is freed. The only connection is the ligamentum venosum to the left portal vein, which can be clamped and then removed. And now we can see the accessory left hepatic, the left portal vein and up there, the left hepatic vein. So, and this is just quickly a splenectomy here. The spleen is attached to the stomach because there's tumor involving the splenic hilum in the stomach. Again, the attachments to the diaphragm are taken down. Exposure is critical here. The costal margin is elevated. Then there's some tumor attachments of the omentum to the splenic flexure of the colon. Here we can staple along the greater curvature of the stomach just to free this tumor in the gastrosplenic ligament along the short gastrics, which is done here. Then we're freeing the omentum from the colon here, again, which is also involved with tumor. Here we're using the ligature device and after mobilizing the spleen and the tail of the pancreas as shown before. Here's a tail of the pancreas mobilized with the spleen anteriorly and medially retracted. And then the splenic artery and vein can be taken here. We use the endo stapling device and the specimen is removed. Thank you. Well, thank you so much for just an absolutely spectacular discussion and video. We've got time for just maybe one or two questions. And the first question will come from the audience. What energy do you use or what energy devices do you use when you're doing the liver resections? I think we might've seen the Aquamantis or the bipolar device there. What do you like to use and where? Yeah, I like to use the tissue link and the Aquamantis because it's really easy to use. It comes in handy, but it essentially just heats up water in between two energy points and it's like a bipolar and it's a very nice instrument. So the tissue link or Aquamantis is for me the most important instrument when operating in the liver. And then just in terms of also instruments that you use, when you're taking the tissue just near to the tail of the pancreas or when you're gonna be doing a distal pancreatectomy along with your splenectomy, do you use a seam guard on your stapler or do you always use stapler or how do you approach that? I use the stapler. I know others like the seam guard. It's too complicated for me. So I use usually use the endo stapler for the distal pancreas. Okay. Well, thank you so, so much again for an amazing discussion and a spectacular video. We're gonna move to our final presenter and video who is Alejandro Rahane from MD Anderson Cancer Center. And he'll be discussing minimally invasive surgery for interval debulking. Professor. Awesome. Thanks for all the organizing committee for allowing me to present today. So we're gonna be talking about a little bit different to prior presentations, MIS interval debulking surgery for patients with advanced stage ovarian cancer. So the next one, so I have no conflict of interests. And first I'm gonna show a video and then I'm gonna be talking about a randomized controlled trial that we're hoping to start in the next two months. And then at the end, I have some slides just to further just touch base about the trial and inclusion criteria and you know, what are the patient population we're looking for within this trial? What are the objectives of the trial? So to start, I think one of the key elements of doing an MIS interval debulking surgery is the entry. I think it's important to keep in mind that after receiving the ischemic chemotherapy, you can have a lot of adhesions. So in this particular case, we use a various needle to get in, but most of the times I use an open approach. I've been involved in cases in which during the entry, just given the amount of adhesions after the ischemic chemotherapy, some of the vasculature was injured. So it's just something to keep in mind. As I mentioned previously, like given the fact that these patients had advanced stage of brain cancer, receiving ischemic chemotherapy, you know, these patients have adhesions and we're just taking down the momentum. The next important thing to keep in mind when they're doing a minimally invasive surgery for after the ischemic chemotherapy is the surgical exploration. Now that to me is a key feature of this approach. I think we are all worried when we are starting to utilize these techniques is that whether we can really visualize all the disease and whether we are leaving any tumor behind. So I think you have to be very, very careful, very, very mindful about that. For this particular case, we used a laparoscopic flexible, a flexible laparoscope. And that really helped us to really look around and better visualize the different structures. And you can see how we were able to visualize the liver previously, and then we're just looking at the mesentery. And again, just making sure that you are really, really carefully assessing all the different surfaces to make sure that you can, first of all, do the procedure through a minimally invasive approach. And second of all, that you're really resecting all the cancer disease. Because at the end of the day, my feeling about doing MIS approach for the ischemic chemotherapy is that if you really feel like you cannot take all the cancer, you should always open. That should be your default. It's something that you can offer patients, but you should not use it for all your patients after neoadjuvant chemotherapy. So here we're open the right retroperitoneum. I think just one thing also to keep in mind after all of you that have used neoadjuvant chemotherapy, you know that all the peritoneal surfaces have a different feeling a lot of times, like they feel like a little thickened peritoneum. So that's what you probably are seeing in this particular video. We're here taking the IP ligament on the right side, and we had really opened all the spaces. We are dissecting the ureter on the right side and really just mobilizing everything. I think one of the key features for ovarian cancer is that really the retroperitoneum many times is respected. So you can really open your spaces and find your different critical structures. So we're doing really, we're doing right now the bladder flap to perform the hysterectomy. Now we're moving to the left side. And here on the left side, the rectal sigmoid is really wrapping the large left of the nexal mass. So we're carefully dissecting all of the cone from the mass and also opening again the retroperitoneal space on the left side. We're gonna start dissecting the ureter. We'll open the rectal, the pararectal and the paraversical spaces. Again, we're gonna keep moving, just dissecting all of the cone from the pelvic side wall. So I think one of the key parts of doing this procedure is really, really using blunt dissection to really open your spaces. I think at some point in the video, we're gonna see how we really open the peritoneal wall on the left side. I think that's gonna come soon. And there was a cyst that we ruptured. And at that point, if you have advanced stage ovarian cancer and you have to rupture a cyst, that probably is not gonna impact the prognosis. And as long as that really helps you open new spaces, I think, again, finding different anatomic landmarks, it's a key feature of doing this procedure of subclinology among chemotherapy. And as I mentioned before, this is where we're really opening the peritoneal wall. We ruptured the cyst. But I think you're gonna see how that freeing up those spaces really helps continue the hysterectomy portion. Here, we're doing the rectum, we're dissecting of the rectum from the rectovaginal wall. We keep dissecting the left pelvic sidewall and the ureter, and then we're just finishing the hysterectomy. I like to take the uterine vessels first and do not perform the colpotomy just because I like to do the omentectomy subsequently. So we have, actually, we can deliver the omentum through the colpotomy. But if you prefer to close the vaginal cuff, that's fine. And you can just take the omentum through, if you have a larger port, you can probably take it through that port. But I feel like it's much easier just to take it through the vagina. So at this point, we're starting the omentectomy. And in these patients that receive neurogenomic therapy, omentectomy is a significant, was an important part of the surgery because that's where a lot of times you see a significant residual disease. I like to start on the right side in the hepatic flexure. I feel like that's an easier, it's lower, and it hasn't, it's just easier to approach that. I feel like it's an easier approach, but pretty much you can use, you can start anywhere. You can start in the middle and you can go laterally. You can start on the left side. Again, that's up to how are you feel comfortable and also depends on the disease burden as well. So here we're continuing, we're dissecting of the omentum from the transverse colon. We're just gonna keep moving upwards and we're ligating the short, we're gonna start ligating the short gastric vessels. You're gonna see how now it's much easier. And it's very important to have your assistant yourself using traction and contraction to really elevate the omentum so you can really visualize all the structures to avoid getting into the mesentery or other important structures. So again, you have to really have the flexibility to use different ports and to allow yourself to, if you don't have a flexible camera, to really move your camera to different places so you can really visualize nicely along all, you know, while you're doing the case. So I think there's a lot of, I feel like there's a lot of port hoping, like you can move your scope through different places so you can actually perform the surgery nicely and you can have nice visualization. Again, here we're just keep dissecting the omentum off from the stomach. And you're gonna see now how we're gonna just finish the omentectomy. I think there's always a fear, especially when you're doing this through minimally invasive approach, that you cannot see very well up to the spinoflexure. But again, I think you really have to be mindful that if you don't feel comfortable finishing this MIS, that it's just better to open, to not leave any disease behind. But I think as long as you keep visualization, have a nice visualization, really getting into the spinoflexure is not usually very complicated. Again, we keep dissecting off the omentum from the transverse and descending colon. And you're gonna see now the final specimen and how we are just finishing taking out the last couple of patients from the omentum. Now we're delivering the omentum down and we're gonna deliver the omentum through the colpotomy. We're just taking again, the last couple of adhesions from the omentum. I'm gonna talk about the LANS trial, but in the LANS trial, I think a big component is the omentectomy. And then we're allowing to, if patients have a complete resolution of their disease after three or four cycles of chemotherapy, it would be fine to do a infracolic omentectomy as long as the omentum looks completely normal. If not, we're encouraging surgeons to do a supracolic omentectomy. Again, now we have moved the omentum. In this particular patient, imaging showed a three centimeter parotid lymph node. And this is just showing how we dissected the parotid lymph node. You can see the different vessels, you can see the renal vessels and how we're just finishing the parotid lymph node dissection. The reason I wanted to put this is because when you're doing a MIS interval of the bulk in, I think it's important to have a good visual MIS interval of the bulk in. I think there's a big component of really relying on your imaging to make sure that you know what you're getting into before doing the procedure. Again, as Raytan mentioned before, it's, you know, when you're doing MIS, one of the biggest limitations that you can really, it's very hard to palpate the different surfaces. So I really think it's critical to really have a good assessment, imaging assessment before you do the case. So you really know whether there's any bulk in the disease that you can really go and resect that disease because sometimes it might be difficult to visualize if you don't have a good idea. We're just removing all the specimens through the copotomy. And that's a key part about just leaving the copotomy to the end. Again, this is, different people might have different approaches for this. I think just this is, this makes the delivery, I think, much easier. And I think we're just gonna close the copotomy with a VLOG suture then. And that's it. Okay, I think we can move to slides. So I mentioned before that we are planning to start phase three randomized, international phase three randomized control trial. The name of the trial is the LANS trial. It's international prospective multicenter non-inferiority phase trial. Next slide. So this is the schema. One of the key features of the trial is that we're very interested in just looking at very peculiar patient population. So we're interested in patients that receive neologenable chemotherapy, that receive three or four cycles of chemotherapy and that have a normalization of the CN125 and a complete or partial response on imaging. But the important thing is that we are actually looking for patients, again, with normalization of CN125. And the reason for that is that we're actually looking for those patients that when you deliver neologenable chemotherapy and you open, and you're like, okay, I should have done this. I could have done this through a minimally invasive approach. So we are restricting this approach to those patients that we feel have the largest effect on their chemotherapy and that would not have, the MIS approach would not have any detrimental effect in their outcomes. So again, once we, it's a very straightforward schema. Once we identify the patients that are eligible for the study, then they're randomized to either receiving laparotomy or laparoscopy after neologenable chemotherapy, and then patients receive further chemotherapy after their procedure. We're allowing patients to be, next slide. We're allowing patients to be involved in other clinical trials, as long as they're not surgical trials. And we're pretty much doing a very pragmatic clinical trial in that. We're allowing maintenance chemotherapy or allowing different types of chemotherapies or again, clinical trials. And just in the way, the reason we decided that is because we really think that that's the usual clinical practice. The primary outcome is disease-free survival. And then we have a lot of other clinical trials that are disease-free survival. And then we have a lot of other surgical outcomes, including quality of life, the rates of optimal cell reduction to normal cell disease, optimal cell reduction, overall survival, and then morbidity and mortality. And the other interesting thing that we're looking at is the number of porcine metastases in the MIS group. Because someone, I think someone asked about that in prior presentations. Next slide. These are the inclusion criteria, and I already talked about them. I think the key thing is just the normalization of CM125 and exclusion criteria. Other important thing about the exclusion criteria that I didn't mention before is that if an imaging, we, the surgeon, we in conjunction with a radiologist, don't feel that the procedure can be done through a minimally invasive approach. Obviously those patients should not be enrolled in the study. And we're trusting that whoever's the surgeon will make that assessment on their own institution. There are two phases for this study. The first phase is a pilot trial where we're gonna include the first 100 patients. And there are three objectives of this phase, of this pilot trial. The first one is we wanna make sure that we can actually enroll the patients because this is a unique patient population. We wanna make sure that there's a crossover rate of less than 25%, meaning that the rates of conversion from MIS to open is less than 25%. And the other important thing is that we wanna make sure that there's not a difference of more than 20% of non-residual disease between the open and the laparoscopic. And when I say laparoscopic, it can be robotic or straight stick, less than 20% between the groups. If we reach these goals in the first 100 patients, they will move on to the first phase three study. We, these are just some of the sample size and analysis. I think the important numbers just to keep in mind is that we're actually looking for 580 patients. Right now we have 12 sites that we are thinking are gonna be the primary sites for the pilot. And then we have other 18 to 20 institutions that have expressed a strong interest and also participate for the phase three study. Okay, I'm happy to take any questions. Thank you. Thank you so much for an absolutely superb video and an outstanding discussion. And I know we're all excited for that trial and be very interested to learn about the results and as it progresses. I'm gonna start our discussion by just fielding some questions from our audience. And for one question was asked, what is the limiting factor for MIS and cytoreduction, surgeon's skill or tumor burden? I think it's both. I would say that the first thing is tumor burden. I think particularly for, and we're talking about, after neonatal chemotherapy is definitely tumor burden. I think if you have a patient that has an absolute response, and I think we all have those patients that we just get three or four cycles of neonatal chemotherapy, they have a profound response, we open and it looks like there is nothing left. So I think those patients, technically we all can do those cases. So I think I would say that first of all is just tumor burden. Okay. Another question from the audience, do you use the PCI in preoperative evaluation? And is there a cutoff for selecting patients for a minimally invasive approach based on the PCI? So I think that is an excellent, excellent question. And when we were designing this study, and Ana Fagotti is one of the co-PIs for this study, PCI, and I'm traveling a little PCI to a little bit of Ana Fagotti's score a little bit. We had a lot of conversation about whether we should, all the patients that were gonna be enrolled in the study should have a laparoscopy assessment first to make sure that you, the surgeon felt that they could have accomplished the approach laparoscopic and then, randomize them after that laparoscopic assessments. So I think we all felt that that was gonna be a little bit tricky to do because there are some centers that they were not doing any laparoscopic assessments. So that's what we decided to do. But I think that's, I think that is a very good question. And I don't think we have data, particular for after neurogenomic computer PIs. Okay. Well, as the session draws to a close, I wanna thank our speakers today for their time, expertise, and insight. I'd also like to thank all of you who are attending. The IGCS is looking to continue our surgical education on a monthly basis. And you'll be receiving an email from the IGCS with a link to this recording, as well as a two question survey, where you have the opportunity to submit any topics you'd like to see in future surgical education webinars. And we thank you very much in advance for your feedback. Our next Surgical Film Festival will be on June 5th, which is again a Friday. And this session will focus on lymph node assessment and gynecologic cancers. Information regarding this session will be posted on the IGCS website and we very much hope to see you there. I'd like to thank all of our speakers again and for all of you who are attending and wish you continued health and safety. We are over time for what we had planned for the session, but there are a couple of other questions that have filtered in. And if our panelists are willing, I'd be happy to ask those questions and people who are interested can continue to listen. Is that all right? Okay. One question that was asked really for anybody is, do you think that the hysterectomy is an obligatory part of an interval to bulking surgery, or do you feel like that's something that might be able to be omitted? Anybody who's on the panel is welcome to answer. Vance, can you repeat the question? The question is, is hysterectomy, presuming there's no disease involvement of the uterus, is that a mandatory portion of a debulking procedure, particularly an interval debulking procedure? Or do you think that that's something that we might omit in the future? I would say that that currently is the standard of care to do a hysterectomy. I think it's very hard. Personally, I think it would be very hard to leave the uterus behind after, you know, for a patient with advanced stage of brain cancer. Yeah, I think I agree with you. I think the question stems from the notion is there are some patients, particularly in very early stage disease or at time of interval debulking that you don't see any disease, or you don't see any disease in the uterus, or at time of interval debulking that you don't see any disease, and you can kind of think of it as just a part of the peritoneum like any other part that you're leaving behind. But I agree with you. It's kind of our dogma and the way we approach, certainly part of a standard surgery, and it would be very challenging to justify leaving the uterus behind without any sort of safety data to support that. I don't know if Dr. Savanovic is still available, but a question came in for him. Do you use any special preoperative imaging of the porta hepatis region to look for any anatomic variations? I use the CT scan, and it's a very good question. Most of these anatomic variations are well known, and you have to look out for them while you're doing the surgery. In order to see those on imaging, you'd have to order angiograms. So I don't do that routinely. So a CT scan with IV contrast is good enough. And then while you're doing the dissection, be aware of those common variations. One is in the porta hepatis, it's the replaced or accessory right hepatic artery coming from the superior mesenteric artery. And the other one is the accessory left hepatic artery, which originates at the left gastric artery. And so you can easily see them or find them while dissecting and look for them. So I always, when I approach this area, I'm always aware that this may be the case. But I don't do specific imaging for that. But good question. Professor Shiva, a question came for you regarding the surgeon volume required to be competent in the procedure you discussed. How many exonerations or modified posterior exonerations should a surgeon or team do to every year to be considered competent or high volume? Well, you know, it's a matter of time, of course, and it's a matter of volume. I would say that, you know, generally speaking for primary bulking surgery, in the literature, we should, you know, perform one out of three cases of bulky disease. So I think that you might be confident after the 15, after 50 cases, I would think. On the other hand, you know, you have to be really confident on managing complications. If it's the case, you have to be very sure when there are the indication for ileostomy and to select patients for that. And follow all the rules that we are, you know, doing as we have been commenting. But talking about volume, I think, you know, after 50 cases, you start to be very confident. But you know, I'm doing, let me tell you, I'm doing my anastomosis, I'm doing every single anastomosis with the care of the first one, trying, you know, to be very, I mean, aware that a complication is a nightmare for the patient. Dovetailing on that question, do you think that centralizing cases regionally helps with that, or is there some other way to try to make the cases more dense and so higher volume surgeons have a greater number of cases? It's a question for me? Sure, yeah, or anybody, but I think for you. Well, you know, centralization and managing care, I think is crucial. I mean, and it's something that has been proved in, I mean, in the literature. So volume of cases, experience of the surgeon, gynecologic oncology, even rather than general surgeons or just general gynecology, so I mean, this is key. I mean, it's completely, I mean, the survival depends on this managed care, you're right. This is my perspective. Well, thank you so much again, everybody, the panelists for participating, the attendees. I think this has been really informative for me and a wonderful session with amazing videos. Thank you so much again for everybody for joining and we hope to see you on June 5th. Take care. Bye-bye.

laparoscopic right diaphragm resection

techniques

considerations

marking

coagulating vessels

phrenic nerve

diaphragmatic defects

feasibility

surgical treatment

gynecologic cancers

radical hysterectomy

pelvic lymphadenectomy

cervical cancer