everybody who's joining. We're going to give a couple minutes for everybody to get logged on and then we'll get started. We're going to wait one more minute for people to join, and then we'll go ahead and get started. We're excited to have you all. Okay. Welcome, everyone. My name is Vance Broach. I'm the co-chair of the Surgical Education Workgroup of the Education Committee for IGCS and a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in the United States. I'd like to welcome you to today's surgical education webinar dedicated to upper abdominal surgery for ovarian cancer. We're thrilled to have you with us today. I'll start by mentioning a few housekeeping notes relevant to the Zoom platform we're using for this festival. The presentations today will be best viewed if you enter full screen mode and adjust your settings to fit to window. Also, the quality and clarity of the video presentations can be affected by the speed of your internet connection. A high speed and wired connection are best for viewing these videos. If the quality of your video stream is poor during our presentations today, don't worry. This webinar will be available to view on the IGCS education portal shortly following the live presentation. We have an incredible panel of surgeons who will be sharing their expertise on upper abdominal surgery for ovarian cancer. There will be ample time for discussion today. So we encourage you to submit questions through the Q&A feature at the bottom of your screen. And we'll do our best to address as many questions as possible during the session. Now, it's my pleasure to introduce Dr. Baton Ribeiro, my co-chair of the Surgical Education Workgroup of the IGCS Education Committee. He'll be co-moderating today's session with me. And I'd like to turn it over to him to introduce our speakers. So, good morning. Thank you, Brooch. I'm very happy to be here today and be part of the IGCS Educational Committee. We have an incredible session planned for today focused on upper abdominal ovarian cancer resections. Now, it's my honor to introduce today's speakers. Joining us are Dennis Chee and Ryan Kan from the Memorial Sloan Cancer Center in the USA. René Parreira from Colombia. Cristina Faltopolo from the UK. And myself from Brazil. So, thank you all for joining us today. Without further ado, to kick off today's film festival, I invite Dr. Dennis Chee and Ryan Kan to present their film, Radical Upper Abdominal Debulking Surgery for High-Grade Ovarian Carcinoma. Dr. Kan, can you share your screen? Great. Thank you. And thank you, everybody, for joining us today. Give me a second as I get our screen going. Great. Can everybody see that? Thanks. Perfect. Radical Cytoreductive Surgery of the Upper Abdomen for Advanced Ovarian Cancer. Volume of residual disease following cytoreductive surgery is one of the most important factors for overall survival. The goal of cytoreductive surgery is optimal resection and, ideally, complete gross resection of all visible disease. Extensive abdominal resections was not initially part of the surgical armamentarium of advanced ovarian cancer management for GYN oncologists. Large-volume upper abdominal disease involving the diaphragm, liver, and or spleen was deemed unresectable and the patient was left with suboptimal residual disease. In 2001, our service at Memorial Sloan Kettering began incorporating the use of extensive upper abdominal surgery into our cytoreductive approach for advanced disease. These upper abdominal radical procedures include diaphragm peritonectomy and or resection, splenectomy, distal pancreatectomy, partial liver resection, cholecystectomy, resection of tumor from the porta hepatis, and intrathoracic cytoreduction. This has led to a significant improvement in our optimal cytoreduction rates and ultimately improved progression-free and overall survival. As seen here, examining the Memorial Sloan Kettering ovarian cancer data over the past two and a half decades, as the CGR rates have continued to increase, the overall survival rates have also increased in tandem. Additionally, unpublished data from Memorial Sloan Kettering has demonstrated significant survival benefits when complete gross resection can be achieved with intrathoracic disease present. One of the procedures we do with reasonable frequency for advanced ovarian cancer is the splenectomy. In this video, we demonstrate a splenectomy with distal pancreatectomy in a woman with high-grade serous ovarian cancer. When approaching a splenectomy, it is important to first gain access to the lesser sac, which is shown here. This is performed in conjunction with a greater omentectomy. The transverse colon is then manually retracted. The splenic flexure of the left colon is then mobilized. The ligamentous structures are then ligated, including the gastrosplenic ligament, as well as the splenorenal ligament. Following the lesser sac towards the spleen you'll encounter short gastric arteries that can be ligated and divided. There are multiple ways of ligating and dividing the short gastric vessels. Here a clip is applied prior to dividing the short gastric vessels. As seen here the spleen and adjacent mass are becoming freed from the surrounding peritoneum. After the spleen was removed from the ligament disattachments it was found that the distal pancreas was also involved by the mass. The spleen along with the mass are gently retracted manually to help with visualization. Once the spleen is dissected off the remaining peritoneum the splenic artery is now identified and skeletonized. The splenic artery is isolated prior to its involvement with the mass and is ligated with a silk tie prior to dissection. Once the splenic vessels are divided attention is then turned to the tail of the pancreas. The tail of the pancreas is then stapled and divided. The mass encompassing both the spleen and the distal pancreas is now entirely removed. Post-operative pancreatic leaks and fistulas are major contributors to the complications and deaths associated with pancreatic resections. Post-operative mortality following pancreatectomy has been estimated to be approximately 2% in high volume centers. Additionally, morbidity after pancreatectomies has remained between 30 to 50%. Rates of pancreatic leaks and fistulas have been shown to significantly decrease with the use of staple or mesh reinforcement devices such as the seam guard. Additional strategies to reduce the risk of complications includes baseriotide, a somatostatin analog that has a longer half-life than octreotide and a broader binding profile. This has been shown to decrease pancreatic secretions and has been shown to prevent post-operative pancreatic leaks and fistulas. Often, super diaphragmatic nodes are involved in advanced ovarian cancer and, as demonstrated, intrathoracic complete gross resection improves overall survival rates. Therefore, if involved, we recommend their surgical removal. In this case, a left super diaphragmatic node was found enlarged on imaging and is shown here. In order to gain access to the super diaphragmatic nodes, a defect was made in the diaphragm at the location of the enlarged node. Here, the node is grasped, ligated, and divided. While transecting the cardiophrenic nodule, a defect was made in the pericardium as fluid can be seen extruding from this site. This defect was then repaired with interrupted 2-0 non-absorbable sutures. It is recommended to place each suture in between heartbeats. Here the repaired defect is further demonstrated. Following repair of the pericardium, the diaphragm is then closed, as well as closure of the contralateral diaphragm as seen here. This concludes our video. Thank you for your time and consideration. Thanks, Dr. Kahn, for that wonderful presentation, and we're happy to open up our discussion for questions now. I'll go ahead and just kick it off by just asking, you know, in the experience that you have at Memorial, you know, this seems like a really infrequent complication and one that, you know, we don't encounter too frequently. What kind of backup is available for, you know, these rare complications, and what sort of folks do you have on standby if something like this might happen? Yeah, that's an excellent question. I would, you know, say surgery is the ultimate team sport, so, you know, definitely having a great rapport with the intrathoracic surgeons, as well as colorectal and HPB surgeons as well. At Sloan Kettering, we have a very close, tight-knit relationship, where if we do suspect that there is going to be a part of an intrathoracic site reduction, we'll reach out to the thoracic surgeons ahead of time to make sure that they're aware and available on standby. Same thing with hepatobiliary, whenever we're doing a resection of the porta hepatis or anything around the liver, gallbladder, or pancreas, we'll make sure to have hepatobiliary on standby as well. And obviously, they're very busy as well, so usually, when we're in the OR, they're also not too far away, so, you know, keeping a close relationship and just open communication is key. Got it. One question from the chat, what are your feelings about the placement of a drain following a distal pancreatectomy? And if you could just clarify if that's something that's done routinely or not. Yeah, so the data is mixed in regards to drain placement. I believe it's definitely depends on the culture and preference on the physician themselves, but as far as a standard or benefit, it's actually mixed in the literature, so a lot of it depends on the physicians themselves. But it can definitely be a great way to identify a leak early on. I know a lot of physicians here place after a pancreatectomy and can be a great way to test the fluid and make sure that there is no leak. Gotcha. And while we're on the topic of drains, how about a chest tube following, you know, a diaphragm resection? So similarly, you know, I think early on, it was placed as standard almost regularly after diaphragmatic resections, especially full thickness. I think over time, there have been studies that have shown that patients may also benefit from not or may not necessarily benefit or have any difference with chest tube placement. So I think that the data we've seen has shown either way. I think if you do suspect that there's a high likelihood of a pleural fusion or extensive resection, you know, absolutely, a patient could benefit if you have a high suspicion for an effusion. However, it's not regularly placed with just a routine stripping per se. Gotcha. I would disagree with that. Hey, Dr. Chi. Yeah. So I've had some battles with Rob Bristow about this and also internally. If you expose the central tendon, that patient will get a pleural effusion if you do a stripping. If you do a little lateral removal, some peritoneum, sure, you don't need to do that. But in a retrospective study that we published and now a prospective study by the Italians, if you do a significant liver mobilization, you are going to get an effusion. And the majority of times those patients are going to get symptomatic. So I don't mean to go against my esteemed colleague, Ryan Kahn, but you do a big diaphragm surgery, you should place a chest tube, period. Unless you want to start doing blood gases and roll out pee in the middle of the night when the patient becomes hypoxic. I'm here just to add some spice. So there you go, spice. One more question that came through the chat. You know, there was the approach you showed was more of an anterior approach or through the lesser sex. Sorry, I got a little distracted by Dennis on the bridge there. So what are your thoughts on approaching the splenectomy with different approaches, either posterior approach, anterior approach, taking the ligamentous attachments first versus getting into the lesser sac? Yeah, I think that I used to do the anterior approach and then I ended up doing more distal pancreatectomies than I'd like. I ended up injuring the pancreas more than I'd like. I think that given the fact that you're not doing this with normal anatomy, oftentimes splenic hylum involvement, I think the posterior approach. I think we may have lost him there as he's crossing from Jersey to New York. The signal may not have been as good. I think it depends on where the disease is and what you have access to a lot of times also. You know, if you're limited from the anterior approach, then, you know, the posterior approach is quite reasonable. And as Dr. Chi mentioned, you're sort of flirting with the pancreas a little bit more when you're coming in to the spleens. Are you back, Dennis? We might have a little bit of connection issues. As other questions come through, we can try to answer them through the chat as well, though I think in the interest of time, we're going to go ahead and move on to our next speaker. So, thank you, Dr. Kemp, for your magnificent presentation, and next I would like to invite Dr. René Parreira to present the film Pulmonary Transthoracic Resection in a Patient with High-Grade Serious Ovarian Carcinoma. Dr. René, thank you. Thank you, Greta, and thank you, IGCA, Asian Amnesties for having me. It is a pleasure to present our case. We are going to address a video-assisted narcoscopic surgery in a patient with advanced ovarian cancer. This is a case of a 72-year-old woman with a remarkable medical history, previously healthy, due to progressive abdominal pain. She complained to the emergency department, was seen by a surgeon, an ex-institutional in a province about five hours away from Bogota, and acute appendicitis was diagnosed, an appendectomy was performed. There was no reliable data on abdominal findings in July 2018. The pathology report, acute non-superior appendicitis, but a high-grade carcinoma. In monocytochemistry, favored ovarian neoplasm with positive CK7 and CA125 and WT1. The CA125 that we asked when she came to Instituto Nacional de Canceres in Bogota was more than 1,000. In the abdominal CAT scan, we saw a CT scan in four quadrants, a left ovary mass of six centimeters with multisystemic appearance and solid pattern, right ovary with the same findings but measuring four centimeters, uterus with myomatosis, a mental cake, no suspicious adenovitis, and a mild right pleural effusion. In the CAT scan of the thorax, right pleural effusion and a left apical nozzle of 10 millimeters. We performed an ultrasound by detour synthesis in October 2018, and the liquid was positive for malignant cells. So we classified the patient as a high-grade serous ovarian cancer, stage 4A. In the multidisciplinary conference, we decided to start chemotherapy, and we'll start carboplatinum paclitaxel in December 2018, and the patient received six cycles until April 2019. In the beginning, the CA125 was over 1,000, and after finishing the six cycles of chemotherapy, the CA125 was 68. So the patient was re-evaluated in the multidisciplinary tumor board. This is the CAT scan, abdominal CAT scan after chemotherapy, showing diffuse peritoneal thickening, mild ascites, but no implants, and a reduction in the omental component of the disease. And in the thoracic CAT scan, the nodule was stable in the left upper lobe, and the CAT scan showed also basal and lateral pleural thickening. So in this conference, we concluded that we would offer hysterectomy, plus bilateral salpingoforectomy, plus omentectomy, plus cytoreduction of all visible abdominal disease. If R0 was achieved, the thoracic surgeons will access the thoracic cavity in order to resect the residual nodule. Susan, can you please the video? Okay, this is the surgical room. We have the oral tract by lumen tube in order to occlude one of the lungs when doing the surgery. This is a monitor for the laryngoscope. And we decided, Dr. Oscar Soskunde, the surgeon, decided a minimally invasive approach. This is not really an interval working surgeon. This is a surgery after chemotherapy in a patient with stage four. So there are no visible disease in the diaphragm, mild ascites, no visible disease in the omentum, no visible disease in the ovaries, a few ascites, some small additions between the abdominal anterior wall and the uterus, the rectum, the lateral adnectomy and ophorectomy, and he finished taking out the omentum. This is the vaginal cover already closed and the patient was left with R0 abdominal resection. So the thoracic surgeon, Dr. Carlos Carvajal, started the thoracic procedure using a single board with two rings and in the fifth intercostal space, they entered into the thoracic cavity with the aid of a camera with a 30 degrees scope. And as you can see, the parietal pleura is free of disease. No pus at the time, no implacable segment of the lung. There are some loose additions in the plate that were released using monoclonal ophorectomy, then the surgeon introduces his finger in order to touch the nozzle and to locate the nozzle, and after that, a laparoscopic flexible stapler, 45 millimeters, is introduced in order to take out the lesion. The surgeon used at this time four shots, four stitches, and at the end of the procedure, the surgeon verifies lung insufflation and not a regular chest tube, but a black eye drain of blake is put in the thoracic cavity. The surgeon is now finishing the resection of the nozzle. A final view shows no residual disease. Now the surgeon is recovering the specimen, the surgical specimen. And it is taken out from the thoracic cavity. A final view of the right thoracic cavity shows no residual disease, no implants, no effusions. And the thoracic team finished the surgery, and this is the piece, a six centimeters long fragment. Can you stop the video, please, Susan? I'll share my screen again. Okay, we have an ER0 resection in abdomen and thorax. After a remarkable POP and hospital stay of just three days, the patient was discharged. Pathology report, omentum, para-rectal implant, and ovaries, high-grade serous ovarian tumor. And the pulmonary nozzle was negative for tumor and fibrosis was reported by pathology department. The patient was deferred to medical oncology and genetic counseling. The patient, unfortunately, did not attend to the appointments and came back 12 months after surgery with abdominal and thoracic carcinomatosis, a tension ascites, a very bad functional status, a COG3. So we decided to not give any therapeutic attempt and palliative care was started, but unfortunately, the patient died two months later. As a conclusion, in centers with multidisciplinary teams and trained ovarian cancer management surgeons, hepatobiliary surgeons, thoracic surgeons, oncological surgeons, and gynecological oncologists, VATS is a feasible tool in the management of advanced ovarian cancer. In fact, the doctors from Memorial Long Catering have a published paper showing that in 43% of patients undergoing VATS, the management can change according to VATS findings. Most of what we are reading now is based in retrospective reports. There are no available research, prospective, randomized clinical trials. And as always, in medicine and in surgery, the key element is the patient selection. Finally, this is the team at the Instituto Nacional de Cancerología that helping the care of this patient. Thank you very much. Well, that was great. Thank you, Dr. Pareja. Let's open up for discussion so you can send your questions through the Q&A. And I have a couple of questions for you. So, obviously, sometimes it's kind of difficult to decide what are the right areas to remove after knee-wedged venoum chemo, right? So, is there any tips or tricks? How do you decide this I'm gonna remove or that's something that I will not remove? Do you feel that it's important to have images before, like with laparoscopy or whatever, to help to decide? Do you use this kind of things to help deciding? How do you do when you operate on a knee-wedged venoum chemo patient? Okay, there is a combination of all the things that you have mentioned. We use images, we use the levels of CA-125, and sometimes we use laparoscopy in order to define if the patient is resectable or not. Most of patients after knee-wedged venoum chemotherapy will be resectable. In thorax, particularly, we depend on the concept of thoracic surgeons. And if thoracic surgeon determines that the patient will be resectable, will depend from an air-zero abdominal resection as we did in this case. But this is not a knee-wedged venoum treatment because this patient was diagnosed with 4A ovarian cancer. So, we cannot cure this kind of patients. So, we are just giving extra time. So, after receiving chemotherapy and according to the good response that the... With the... Decided to complete the... In this type of cases, I think to individualize treatment is key. So, every person is different and every person should be analyzed by the whole multidisciplinary team. I agree, that's a difficult question. Sometimes there are a couple of questions about the morbidity of the surgery. So, how do you decide this patient's going to a thoracic surgery and when not to do it? So, I have a question about morbidity. So, how far you think we should go? What kind of pulmonary resection should we try regarding the morbidity of the procedure? And also, when do you use... Obviously, we always use drains after a pulmonary resection, but there are questions why... When do you remove a drain after a pulmonary resection or after the phragmatic resection? How do you decide that? And then you can comment about morbidity of the procedure. Nice question, Raytan. The morbidity of the procedure depends on the size of the pulmonary resection or the size of the pulmonary resection. It's just a small surgery, very long. So, we don't expect to have any important morbidity. How do you... For regular chest tube, they use 90 centimeters possibility a day and 30 centimeters in the second possibility days. The thoracic surgeon used to remove the drain if it produces less than 70 centimeters. I've seen a patient when the phragmatic resection is really high. So, suddenly a... ...is frequent in the screening on the size of... Okay, so one next question, it's sometimes the nodules... Could you hear my explanation? Yeah, there is a small period of time when the communication is not that good. So maybe one final question, because also of the time. So sometimes pulmonary nodules are not so easy to find during the pulmonary resection. So do you have any tips or tricks for marking those nodules? Because sometimes it's not easy to find them. And have you considered to use needle aspiration to check if there is still tumor on the nodule before operating on those kind of patients? These kind of decisions are usually not by us because we don't have experience in management of the thoracic cavity. So in our multidisciplinary conference, thoracic surgeons are involved in the global management of those patients. They usually prefer to remove the peripheral nodes that are easy to take out. And they sometimes use punctures, but it depends on their determinations. Okay, good. So thank you. Thank you, Dr. Padilla. I think we can move on. My pleasure, Reitan. Thank you so much. So great discussion. Next, please welcome Dr. Cristina Fotopoulou presenting splenectomy and mesenteric stripping. So thank you, Dr. Fotopoulou. You can go ahead. Thank you so much, Reitan. Thank you so much, Dr. Ribeiro. The whole team that I'm here today, you have seen very nice videos on splenectomy already. I'm going to show you a less sophisticated one than the one that Dennis and his team showed. So can you see my slides? Yeah. Splenectomy and mesenteric stripping. Let's start with the mesenteric stripping. This is the main limit of probability in ovarian cancer. Unfortunately, it has very high inaccuracy of preoperative imaging. There is massive difference whether there is a small, whether there is a fine nodule carcinosis or a large volume carcinosis. We know that if you have a disease along the actual cirrhosis of the bowel, it's massively different than if you have disease. If the actual bowel cirrhosis is free and just the mesentery is diseased. And when you do mesenteric stripping, which is technically possible, there is a potential high morbidity. And we're going to talk about it and also about the tricks and wicks of how to proceed to proceed there. So this is a patient that I was operating life with an extensive carcinosis. As you see here, really retraction of the mesenteric root. I am used to operate with a bipolar forceps and scissors. And you see here how the actual small bowel is actually, this is the ileocecal area, is actually free. And the problem is this in the mesentery. So the issue here with this case is that even though it actually all sounds or seems terrible in the majority of the cases, it is all relatively superficial. And the minute that you go beneath, it's actually free. The problem with this dissection is that by doing that, you may injure or very often, sometimes there is a risk of injuring the mesenteric vessels, the ileal and jejunal arteries that feed the bowel. If you do that, the problem is that if you go very close to the small bowel cirrhosis, the problem is that they might be not at the minute of the operation, but later. Day five, day seven, an ischemic injury of the bowel and the patient might get a peritonitis and the perforation. Therefore, it is very, very important that you do a tangential resection of any nodules. You see here how the mesenteric root is completely open and the ileocecal area that was completely distracted and completely retracted is now free. Any small nodules that you can palpate again in a tangential way to remove them. I have needed once many, many years ago to reoperate a patient actually on intensive care unit without even having time to bring her back to theatre just because she had a compartment syndrome and she couldn't even be ventilated anymore from a peritonitis out of an ischemic injury from mesenteric stripping. So it's very, very important when you do this procedure to palpate. You see how I palpate the vessels that are feeding the bowel so that they are not injured. You can do that theoretically with the entire mesentery of the bowel and you can do that even on both sides, on one end of the other. It helps if the patient is not very, very thin because the more fatty tissue they have, the more buffer you have in these cases. However, it's a procedure that needs to be done in a very careful way and it is also very difficult to be done probably laparoscopically, so I have never done it laparoscopically. There is a massive issue if there is a carcinosis like a pearl necklace, I say, along the entire small and large bowel cirrhosis, in which case this is not resectable. You can't strip the way we strip so close to the small bowel. You see here there was a little hole or a larger hole, which is not uncommonly the case, but it is actually possible to just, without having a problem in the vascularization of the bowel, just because the fact that there is a hole without any bleeding means that you haven't injured any large vessel. Importantly, any such defects are being closed so that there isn't an internal hernia of the bowel later. It is very important that the minute you close it that you don't, with your suture, practically stitch a vessel and compromise the vascular supply of the bowel through the suture from the closure of the defect. We continue here the mesenteric stripping along the area towards the stomach and the mesenteric root. Again, same principle, in order to be able to strip the entire mesenteric. It is not uncommon that mesenteric disease can be removed that way. However, if there is massive retraction of the mesenteric root, if there is small bowel actual cirrhosis carcinosis, this is not possible. Now let's continue to the next slide, which is the splenectomy. You have seen a wonderful splenectomy by the Memorial and Sloan Kettering film. We know from the LION data, which is the largest prospective randomized study of primary debulking in advanced ovarian cancer, that approximately 20% of the patients with a primary debulking will need a splenectomy. Dennis talked about the necessity of distal pancreatectomy. I fully agree with him, actually, that depending on the way that you dissect, and I'm going to show you how we dissect the pancreas away, very often a distal pancreatectomy that is thought to be needed is actually not needed. A distal pancreatectomy due to true disease in the pancreatic tail is not as common as we think. The most distal pancreatectomies are being done just because the spleen is close to the pancreas and it's not being dissected in a way that the pancreas can be spared. I think it's an issue of just being a bit more careful with the dissection, so that we spare the pancreas and reduce the surgical morbidity, just because the majority of the morbidity events postoperatively from this type of procedure is actually from the pancreatic resection, not from the actual splenectomy. Let me show you the video. After we are dissecting away, you see here all the vessels from the large gastric curvature, again a live surgery. I personally will be very careful in going with a diathermy very close to the stomach. As you see, I have ligated all vessels, just because there have been some cases where I was very close, or my colleagues have been very close to the gastric sclerosa, and then again a week later, it's not during the operation, there is an ischemic injury of the gastric sclerosa and then a perforation. You see here entering the lesser sac, and you see how the pancreas is actually finishing here. This is a very thin patient. You see how the stomach and the omentum are so close to the pancreas, that actually you can dissect it away in order to spare the pancreas. This is a very nice case where the pancreatic tail was completely free. That is why it is so nice to demonstrate. You see here that I follow the posterior approach. In the majority of the cases, we follow the posterior approach, especially since often we have diaphragmatic disease. I will take it and block with the diaphragmatic peritoneum. I'm dissecting away the spleen. It's already dissected away from the diaphragm so that I have it in my hand. You see here how we dissect the gastric abrevis, so the short gastric arteries. Tension and traction and counter-traction are the most important. I will always use the avascular space, as you see here, in order to dissect it again with sutures. I'm very careful to use very close to the bowel or to the stomach, especially diatomaceous earth, the old-fashioned way, with scissors and a knife. You see here that by dissecting the stomach, there is very often disease here. It's important to see the ligation of the arteries here, so that it's a better overview. In that way, I have never actually had problems with ischemic gastric perforations. The few times that I have lived and I have had to reoperate somebody from a gastric perf, there is actually a very high mortality. We have had patients who died from this, so we need to be very careful with the stomach. Here, dissection again of any disease. There is often disease in the gastro-spelenic ligament. Again, to dissect it away, I usually will use the bipolar scissors in order to use the avascular space and distance it from here, as you see here, through dissection in the avascular space of the stomach. You see here how nice you can see the pancreas. By using the posterior approach, you can practically flip the spleen so that the pancreatic tail is not injured. Again, ligation of any vessels. Then, after the spleen is completely dissected off and pedunculated from just here, from the splenic hilum, you see here the pancreas, you see here the spleen completely mobilized, and with just a section, again, from the posterior way, away from the pancreas, using the bipolar scissors, the pancreas can be spared. There is a sophisticated way to do it, like Dennis showed, with a ligation first of the splenic artery, so that there is like an auto-transfusion. You ligate first the splenic artery, and then the splenic vein a few minutes later, so that any blood, there is approximately half a litre of blood in the spleen, so that any blood that is in the spleen can come out. There are many of the vascular general surgeons who will say, here is the artery, here is the vein. If you suture them together, there might be sometimes rare cases of AV malformations or aneurysms, therefore it is actually better to just ligate them separately. To be honest, I very often just ligate them together, like in this picture, but very nice skeletonized, and I have never had problems. You see here that the pancreatic tail is here, a very good distance to the actual splenic vessels, which again I will suture with 2-0 PDS, so that there aren't any ischemic injuries, neither to the stomach nor to the pancreas. Thank you very much. That was a wonderful presentation. Thank you so much, Dr. Fotokoulo. I'm a big fan. I'm a big fan of you, of all of you. That's awesome. We are going to open for discussion with the audience. We already have some questions. The first one is about perfusion when you do this kind of mesenteric resection. Are you using ICG, and how do you perform? That's a very good question. Even though I work in the UK, in Imperial College London, which is a very rich country, we actually haven't managed to buy ICG because of lack of money in the NHS, in the national health system. So I managed to actually buy one last week, and we have been working with the ICG machine since a couple of years with a leasing, so we had it in and out because Strico was just very nice. To be honest, I've been trained to operate without ICG, so yes, it's great if you have it, but it's not necessary to have it if you don't have it. You can always palpate and see the vessels. You can use the aphanoscopy with the light to see where the vessels will go. These operations are four or five hours. If you see that at the end of the operation there is something cyanotic, then you have your answer, really. So yes, ICG is great, but it's not that if you don't have it you can't operate safely. Yeah, I agree. Well, the next question is an even more expensive one, let's say. Do you like to use other ablative techniques, like Cura or any other devices? No, I'm very cheap and very traditional, so I will use the bipolar forceps and scissors, which you have seen, which are great to strip in a way that there isn't a lot of bleeding if you follow the vascular space. In the last years, I've started to use the small jaw, the covidian, the small jaw of covidian, but the small, not the large. I mean, I'm a woman, I don't have very big hands, so I like it to be relatively small as an instrument, but that's all. I don't like a lot of plasma jet or any Cusa techniques, perhaps because I'm not used to operating with them and because I have very good results with the instruments that I like. I think, you know, it's like with every warrior, you use the guns you like and you're used to. Okay, yeah, good. So I have a question, there's always questions for for drains and I have, I always like to ask about, people like to use drains and we always ask, when are you going to use them? And I like to ask, when are you going to remove a drain? So how do you decide to use them? Do you use like the volume or suppression? Yeah, so I was trained many, many years ago to always, when you do a splenectomy, to put a drain in the abdomen, just normal drain in the abdomen for the rest of the abdomen and a specific drain at the pancreatic tail, at the resection bed of the splenectomy and to measure everyday lipase and amylase and see how the volume, the levels go and then when they start to fall, to remove the drain. That's how I was trained many years ago. I have stopped since almost 10 years doing that. I just do a splenectomy, I don't put any drain in that area. There are even some case reports that say that the actual drain at the pancreatic tail might actually injure the pancreas, so I don't want it. I have stopped measuring lipase and amylase since a decade and I haven't had any problems. So I think there are many things that we do just as a ritual without having any real significance. If of course you see that the patient has postoperative, it's usually a week later, high CRP, high white cells, she doesn't behave the way she should and you do a scan, even an ultrasound and you see a big pancreatic pseudopsis, yes, you need to drain it. But to have this ritualistic approach of everyday measuring whatever lipase and pancreatic enzymes, I think it's not necessary to be honest. Okay, good. So, Brooke. Yeah, thank you so much for an exceptional presentation. That was really fantastic and it's my great pleasure to introduce Dr. Ribeiro who will be presenting on laparoscopic diaphragm resection. So can you share my video? Okay, good. So thank you, my good friends, for this opportunity. I'm going to show you a video about right diaphragmatic resection using MIS. I don't have disclosures for this specific presentation. Obviously, it depends on the case and you should not do it for big tumors or advanced cases, obviously. This is for highly selected cases, not cases like those two I'm showing you. We usually, mainly for very, very limited disease and you have to be very patient to evaluate all the abdomen, make sure you are able to remove all the disease. So this is the kind of cases we like to use MIS, but be aware you have to look all the sites and be sure you are going to manage to remove all the sites. So just to remember the some basics about the diaphragm anatomy. So you have a innervation that comes both from the bottom and from the upper part of the diaphragm and usually it runs along with the vessels, the phrenic vessels. So you should try to damage those nerves. You should, obviously, most of the time you can't, but you should try. Also, knowing the ligaments or the liver ligaments will help you to assess the full abdominal cavity and especially in the retro, behind the liver, which is a site that you find often tumor. So you cannot use your trochars placement that you usually use for pelvic disease. So we place extra ports in the upper abdomen and mainly one, it's one of the ports, it's a sub-suphoid port and another one, which is our subcostal, it's in the middle line, depending on if you are going to operate just on the right diaphragm or if you are going to operate on both sides. So in the midline, it works for both sides, but again, you have to be very limited disease, otherwise you can't do it using laparoscopy. So this is the team positioning and we start doing marks in the peritoneum so we can make sure we will remove all the disease. And why we do that? Because once you start doing it, there will be debris all over and some sites you grasp, there will be marks and it may cause some confusion. So we start marking to make sure we remove the area where there is disease. So the best way to do it using the harmonic or a bipolar. And the reason why you should not use a monopolar energy is because there is always contraction when you use a monopolar energy. So you see, we do marks just to make sure we are removing the entire area with disease. Stopped a little bit for me. Okay, so this is now I'm showing with the monopolar how dangerous it is because sometimes there are contractions, you may just perforate the m causa of the pneumothorax. That's not a big issue because you can just suture, but the problem is sometimes this pneumothorax will reduce your space in the abdomen, you lose space and you cannot do it using laparoscopy and you need to convert. Then we start detaching the liver and we do that to make sure we can see all the disease because sometimes there is bulky disease in the posterior part and then you may not be able to do it using laparoscopy so you can convert right away. Here we are detaching the coronal ligament so we can mobilize and we also know that's the limit where the disease anteriorly will be and then we move along the lateral parts to the triangular ligament so we can mobilize the liver. So different from open where you can do it without cutting the ligaments, you can just go around the liver and then posterior cut the ligaments with laparoscopy we start cutting the liver ligaments to assess the entire cavity. Then I prefer to use harmonic energy but you can use a bipolar or whatever just to make sure to pull the tissue against you to avoid sectioning the muscle of the diaphragm unnecessarily. So as you can see when you are in the muscular part of the diaphragm that's quite straightforward, that's not so difficult because it detaches easily but one thing you should be aware that you must have blood, it has to be bloodless otherwise you just get messy and you cannot see what you're doing. Once we have done this section all around so we know what we have to do, you can detach the muscle using sharp dissection and coagulating the small vessels you find and I like especially to use the harmonic because close of the nerves and close of the vessels you can avoid damaging them if you use energy like a monopolar with high energy all patients will have a paralysis of the diaphragm something you know sometimes it's quite bad for those patients with bulky surgery, big surgeries. So you see and but most of the time especially for knee adjuvant after knee adjuvant chemo is very difficult to detach the diaphragm especially close to the the tendinous part of the diaphragm and close to the vessel so you have to be careful and just go slowly take your time do some coagulations and I don't like to do like a mass coagulation you can do it it's faster but you have more paralysis. Then you see as you go around the liver you can use a retractor so we are now moving to the lateral part of the dissection and you can use a retractor and then just go around at the tip of the triangular ligament and then you can move to the posterior part but it's a different approach. So you see now we are finishing the dissection and this is the image we have most of the time you can see you can remove basically the entire peritoneum of the diaphragm that takes some time but it can work it works. So you see this patient with a paralysis because we burn too much close to the vessels and you have you will burn also the phrenic innervation so but this is temporary most of the time in a couple weeks they will have the movement back so just be aware that the more you burn more paralysis you will have. So this is the final aspect after you have removed the anterior part of the peritoneum over the under the diaphragm. Okay so this those are the specimens sometimes they are quite big but there's you can see there is no bulky disease this is superficial disease. Again this is after new adjuvant treatment so this patient we have a small opening communicating with the thorax so you have a pneumothorax and sometimes it's make you start losing abdominal space so you have to suture right away and if you do it and then you just you can aspirate the thorax I don't use thoracic drains for all patients depends on patient's age and other factors so I don't don't use for all of them but sometimes we do guided aspiration of the fluid one or two times after surgery if we need it or we place a chest tube if we need it. But definitely if you do a high pack then you have to drain all patients that that's for sure. And this is just showing how we suture those those patients and we aspirate the pneumothorax and you just move on with your procedure. But again this is a new adjuvant chemo a patient who got new adjuvant chemo so it's much harder and to differentiate the disease from the fibrosis and so on. So most of most of the complications this is from the NSG so you all know we have had some hernias too but none of them were big ones or symptomatic none of them were operated because of this. So thank you so much again for this opportunity. Okay thank you so much for an absolutely terrific video and discussion. We'll open it up for a few questions. The first is you sort of addressed this a little bit during the video but we'll just ask again more formally how often do you do you encounter diaphragm paralysis and to what degree and and post-operatively how do you manage that? Yeah most of the patients have some degree of paralysis depending on how bad it's going to be the the diaphragmatic resection we prepare those patients we even do physiotherapy before surgery for some cases because they have innervation coming from the intercostal nerves so they this is something they can work out let's say they can be prepared and that's also why they they have some movement after surgery in spite of even ligating or resecting the phrenic nerves they still have some movement. So we do lots of physiotherapy after surgery all those patients have some physiotherapy after surgery and if there is a big resection we always use drains and we wait until less than 100 cc to remove the drains sometimes it takes one week or two ten days I just don't like to use big huge drains I use smaller ones because usually there are no clots so there are no no blood so they they work well this way and I try to remove as soon as I can but still you have to be to be aware that some of those patients we have some sort of difficulty to to ventilate after surgery. Gotcha and how about a question from the audience do you use ever an adhesion barrier when you do these cases or no? Yeah I never did it never did use it I don't know but I think that cisplatin it's a carboplatin it's the best adhesion barrier ever I cannot explain that but it is incredible how those patients doesn't have much adhesions after surgery when they get chemo. I don't know I can't explain that. How about there's a question from the audience about the junction of the muscular part of the diaphragm with the central tendon tends to be a place where tumor is densely adherent and may be a challenge to separate the peritoneum in that area any tips or tricks for that is that something sharp blunt dissection something that you can address? Yeah that's a that's a that's a good question because I don't have a good answer for it usually we just try to to detach it and we just go and as you go you feel if there is some invasion and there's very hard to to anticipate if you are going to remove it or not yeah that's difficult. All right well thank you so much again for such a terrific presentation and that is all the time that we have for today so I would just going to show a few slides here. So I'd like to start just to close by thanking all of the IGCS staff for who've made this possible particularly Ashley Johnson, Megan Anderson who's advertised the webinar and also a special thanks to Mandy Hansen who's I've gotten to work with over the last two years and who's sort of transitioning her role within IGCS but I had the great pleasure of working with her. I'd also like to thank all the speakers today for their time their expertise and insight and lastly I'd like to thank all of you for attending. The recording of today's session will be available in the IGCS members education portal by the middle of the week. IGCS plans to continue surgical education offerings including film festivals such as these on relevant topics and dates for future sessions will be emailed in the chat box. And dates for future sessions will be emailed and shared on the IGCS website and through social media very soon. IGCS will be offering the webinar genitourinary system for the gynecologic oncologists. This is supported in part by intuitive and will be on Friday March 25th at 7 a.m eastern time. Details will be emailed and shared on the website. Also of course the IGCS annual global meeting will be held in September this year September 29th through the October 1st in New York City. Abstract submissions are open and there will be in-person and virtual participation options that will be offered for this meeting. Visit igcs2022.com for more information. We wish you all continued health and safety and stay well and thank you again. Bye.

video content

surgeons

surgical techniques

upper abdominal surgery

ovarian cancer

pulmonary transthormic resection

high-grade serious ovarian carcinoma

splenectomy

mesenteric stripping

laparoscopic diaphragm resection