Robotic End Colostomy Reversal

CHAPTER 1

I am Dr. George Velmahos. I'm a Professor of Surgery at Harvard Medical School and the Chief of the Division of Trauma Emergency Surgery and Surgical Critical Care at the Massachusetts General Hospital in Boston. Today I am operating on a young male patient who was involved in a motorcycle crash about five months ago in an out-of-state collision. And he was managed in another hospital with multiple injuries. He received an exploratory laparotomy and the surgeons there repaired multiple injuries, including liver lacerations and a transection of the sigmoid colon for which this patient received an end colostomy. He developed multiple postoperative events. He came back to Massachusetts. He was managed for all this, eventually did well, and today he's coming back to receive a reversal of his end colostomy. We have decided about the multiple options, the multiple access possibilities, and we have decided to perform that robotically. So today this patient is coming back for a robotic reversal of his end colostomy and reconstitution of his bowel continuity. I am planning to insert the robotic ports. I will use four ports and I expect there may be a lot of adhesions at the beginning of the case. Depending on the location of the adhesions, I will deal with them laparoscopically at the beginning and whenever I create enough space to dock the robot and continue that robotically, I will take care of the rest of the adhesions robotically. Hopefully I will not have to open, but I have discussed this as a possibility with the patient. After I clear the field from adhesions, I will dissect the end colostomy, make sure that the vascular supply is well preserved. I will transect the colostomy very close to the fascia and leave the last part of the end colostomy still attached to the skin. In this way, I'm not going to lose insufflation throughout the procedure. I will also dissect the distal end of the colon, the remaining sigmoid, make sure that both ends are adequately mobilized so that I create an anastomosis without tension. And as the last part, I will perform an intracorporeal hand-sewn two-layered anastomosis. After that, I will clear the intraperitoneal part of the procedure. I will remove my ports and the robotic part, and approach the end colostomy, remove this last part of attached colon to the skin, suture the fascia, and hopefully finish the operation there, uneventfully.

CHAPTER 2

Thank you. And the Veress? And a sponge please. And a sponge. Okay. I'm not sure, but we'll see. He must have... Kelly, can you put the insulation on please? Yeah. Alright. Can I have a pen please? Thank you. If we go the first one here, the second one there. The third one here, and the fourth one there. Are you okay? Alright. Okay. Well it seems that I hit the aorta here. Skin aorta. Skin aorta. Alright. Okay. Ready to get in. So why don't you get in there? And you want this to be the eight? Yeah, that will be eight, eight - eight, eight, 12, eight. Hmm. Okay. Yeah, you're in. It's just a lot of adhesions. Didn't really feel like a pop. Oh, no. I don't know that you're in, is it? No. And I'm not sure that you're in. No, no. No, no. Yep. Yeah, now now I get in. Yeah. That looks like bowel. I know it's bowel. I know. That's fine. Maybe go towards his pelvis. Yeah, we are going... Well, it's... There we go. Yeah, it's omentum everywhere. The omentum is stuck, so. Yeah. Wow. Oh man. Okay. It's gonna be awesome. Let's see. Do we have anywhere to put the others, ports? If you go all the way down. All the way, all the way. Can I get room lights down, Kelly, please? Holy cow. Yeah, there you go. Oh boy. The omentum is all stuck there. Wait, we'll go over here. Let's see if can get it this way and then come down on top, maybe. You can do it. You can do it. Hmm, it seems to me that our big robotic preparation will go... So, because that's your midline. Yeah, but that's all omentum right there. That's what I'm looking at. Yeah. It's all omentum. Here's where I'm pushing. You go... Yeah. Lateral. Yeah, I would say that our best, yeah. This will be the falciform there. So our best bet is down here if there is anything, if there is any room to... I mean the omentum is stuck. Can we move your gas to... Wait, right there. You can get in right here. Yeah. Can you move your gas to this port so we can insufflate the side better though? Hold on just one second. Let me just see where I'm pushing a little bit better. Literally right there. Sure. Yeah, it's, yeah. The omentum is all the way up, all the way up. Can I take this? Sure. I mean... See if I can get some insufflation, just don't come out because now you're airing the port. See if it gets better. Where am I? So this is too close to you. This one. Let's see... That one over here but I gotta go underneath that. Like, you're clear right here. Okay. That's right where you're poking. Well, let's put it there and... Then we can... Yeah, let me just go on the other side and laparoscopically take some adhesions and see where it goes. Yeah, yeah, yeah, yeah. Let me have... I want to stay. Laproscopic Maryland, liggy. Yes. Yeah, maybe there's one with the thoracic one by chance. Well, I mean come back. Come back. Yeah. Yeah. There I am. Yeah. Oh yeah. Good. Perfect. Okay. So... Good will be an overestimate. So yeah, let me have anything you have like a Balfour, blunt or Maryland, yeah. So let's see, where does this go? Lauren, can I have my igloo guy? Okay, so can you see me? So wait, wait, wait, wait to see where this is, yeah, yeah. You're right above me. You're right underneath that little... I know, but somehow you have to see the bigger picture here. Yes, there you go. That's it. So let me just come towards you and see what can I... All this is omentum here. Now, let me go down, drive me down a little bit down there. Give me - all the omentum is stuck. Let me go up. I think... I'm getting you a liggy. Yeah. All the omentum is stuck up there. And you know I'll cause... Well, I'm getting you a... I will cause... Can you gimme blunt? 'Cause this has big jaws and I cannot... Thank you. We can get you with the Bovie. If I clear this... The other thing too is if we just clear up north. Well, I'm thinking... We keep the robot on you and take these down robotically. Yes, but we cannot clear up north. So, I'm thinking now that I may need to develop that side to put a port there, because this is all omentum here that is stuck. Let's do this. Do you want to go through the lower port and I'll go through the upper port? You're looking down. You're not looking towards me. I think you're looking down. Come back a little bit so that I see myself. Oh. No, no. Let me just make a little bit of space and we'll put more. Okay. So now we have - all this, we have open, right? So let's change again now, see whether I can go a little bit up. Yep. Right where... Perfect, perfect. Yep. So this is there and I'm here now. And, okay. Well it's that I am under the omentum. You see, that's the problem. I'm under the omentum. I have to be over this omentum. Yes. Exactly. This thing has to come down. But, let me work a little bit there first. I can clean the camera too in... That's alright. That's okay. Want me to come back a little bit towards the board? Yeah, we will change again in a minute. Do you want to clean up the camera a little bit? Yeah, I do. Thank you. Perfect. Okay, so let me just keep on going up there to create more space. I have to avoid this vessel there and here. Let's keep on going up. There. I'm maybe getting close to the colostomy. So where I am, let's go even more laterally. If I can, I'll be totally against you, but that's fine. And there, do I have bowel there? Yeah, there is bowel. Yeah, yeah, yeah, Yeah. There is bowel there. There is bowel. Firmly stuck. Let me go even more laterally and see the extent of the bowel. That's all right. No, I know. I can't get to you though. Yeah, uh-huh. Okay. I'm limited by his thigh. But can, can I do put a five here? Just one second, Lauren. Let me just go as much as I can there. So this is all... I think then you can... Yeah, this is all bowel, here. This is working for... Yeah. We'll see more. Yeah, yeah. Clearly. The thing is that this is really firmly stuck here. And where am I? Here? It's right at the midline. So, do I have access to the left of the midline? Lemme look. One second. That's what I'm gonna look at right now. I think you will, because there, if this does not seem to be bowel over here. Yeah. But you just have... So if it's there, yeah. Let's see where I'm pushing. Can you look there? It looks to me like omentum. I'm going behind you. I know I was... Yeah. Yeah. Let me just, I know, I know. I know. But if I can push it down gently because this is dissectable. Follow me on my move. Follow down, follow down, follow down. There. There you go. That's fine. That's all right. And there. You just have something in front of my port. So every time you pull it... Still, I am creating some space there. Bowel. Yep. Hold this. Can you come up to here and pull this down because that's an open window right there. I'm sorry. What? Say that again. If you look, see this thing in front of my port? Yes. Yes. If you pull that down... Yes. I think you'll have a clear spot because bowel seems to be back here. Okay. We can try to put the porters right here. Okay. Let's follow me slowly, slowly. I don't think that... Maybe not. But maybe we switch ports again. And you grab from this port and pull it down. I'm limited by his thigh. You know, we may just do what Lauren suggests. Just put the port there and then everything will become easy. Let's take a last stab on it and we'll see. Oh god, sorry. No, no, don't worry. It's the omentum and we are through the omentum there. That's the issue. So in order to pull this omentum down, let's see. Okay, this is the colostomy that I'm doing. I have to come very much towards you. So follow my - follow me, follow me. So I'm here, keep on following. And keep on following. And now I'm totally against you and follow there. And this is nothing. And again, I'm on this side. So I don't think that I can come. Let's try... Yeah. Yeah, let's, let's put a five there. And we can go to air seal mode, which should help. Okay. Okay. So then let's switch this. Take this over here. You need this part here. And then I need the inner part of this so... You can't put that out yet. Take it. Can I have, yeah, the blunt? Let's see what we can do here. So I really want to go against you there. And so here is, I am on this part. Okay. Alright. Let me just go up on the omentum. Show me up, up, up. And let's get a good view, because I will need the, the distinction. I'm gonna move to here because I'm on the patient's side. And if you want... I can't get that angle you want from here though. That's all right. That's all right. Just, there you go. Okay, so now let's go down, let's go down, follow my tips and we'll move slowly together. Let's do one last effort here and see what we can do. Okay. So, let's follow my tips. Okay. Right there. Just stay there for a minute. Stay there. I am... Completely blind right now. Yeah, I know. But, that's good surgery, When it's blind surgery, you know, it's... Bowel there. Yeah, yeah. Okay. Getting there. Okay. And a little bit more. Just follow my tips, see if possible. That's fine. We're almost there. We've created enough space to, to work there. That's good. There. Let me just try to grab this. I mean, if you're working here, I can also move you here. You can move there? Okay. Yeah, I think so. Yeah. Yeah. You're just gonna come at yourself. Yeah. Yes. Is that okay? Oh, it couldn't be better. I mean, suddenly it became easy surgery. This is it. That's the interface of the omentum. And if we drop the whole thing down. Okay. Right there. Yeah. So let's see here. Now a little bit towards you. And this is, again, plenty of omentum here. We have - okay. No, I can't. Yeah, yeah, yeah. Yeah, I can't there. Which one do you want? This thing that is hanging? No, no, no. The layer right next to it. So maybe they're just a little bit more and go close to me. Okay. This is all free. Right in front of this port now. Yeah. But now I can probably switch again. Yeah. Hold on. Bear with me, no, George. we're stuck in front of this port. We gotta rip... I know, I know. But I... Come back here. I don't have... And where's the port? I'm gonna bring it to you. Oh, okay. Okay. That's it. Now you're good. There we go. Alright. So, okay, right there. There is a vessel there. There is a vessel here. Can can you connect me with something? Yeah. How's that connection? Oh. Squeeze again. There you go. Okay. Oh, Jason, yeah, we had a little problem here. Just a little one, but we're almost done. Perfect timing. But, we're almost done. And I'm against you, right? Yeah. Am I against you? Okay. That's fine. That's fine. I'm actually - it's good. It's good. Just follow me there. You can also just cut, George, we can figure it out later. I know, I know. But, if I am in the interface, I'd rather not fill everything with smoke. Okay. We got air seal. Just smoke evacuate it out. Yeah. You won't see any smoke. What do we have now? So up there. We'll do that robotically. Do we have access on this side? Let's see. What do you want? We need this one up here. Yeah. This we need a little bit more. And that's where the bowel is, right? This is where the bowel is or not? Let's see. I thought the bowel was more midline. More midline? Yeah. That's bowel down there. Yeah. I think up here... We started like with everything being crazy, crazy adhesions everywhere. So let's see, we are here. Yep. Almost there. Be careful there. Yeah. Yeah. And, where am I now? Pretty good. I think we can do it. Yeah. It's just that this thing. Just come a little closer to me. This is where all the liver abscesses were, so everything is stuck there. Yeah. That's all liver there. Let me just go here a little bit. Follow me on my... This is colon here. This is all the transverse colon. And let me see, where is this? So, it's right there. So I really have to put my ports low. If I have to use these three ports and then we'll see for a fourth one on the robot, I think that I can - do I see all, all three ports or... Yeah. And I can dock this arm later. Yeah. That's what we'll do. Okay. And did we ever see this? No, not yet. No, not yet. Not yet. So we have one. We will be tight. Huh? And where's the other one? Where's the lower one? So this is one, and this is the other. Is it possible for me to do this for you, George? No, it's good. It's good. It's fine. It'll be tight. It will be tight. But you know, once I do a little bit of dissection, it will open up. All right, well let's dock for now.

CHAPTER 3

Okay. So, perfect then. We can use scissors on four, connected. And I will start with the Cardiere on two. Okay. Good to go. Alright.

CHAPTER 4

Okay. So let's see what we have now. So, okay, so this is the transverse colon. Behind there is our - somewhere is our needle, okay. Our liver is not as bad as it seemed. Bleeding. We will suck it out. I don't think it's anything still going, but we'll see. It may be, maybe it's bleeding from the port itself. Yeah, this is what's dripping. It's dripping from here. That is what is dripping. Yeah, that's what's dripping. Let me just work here a little bit and see where we go. Maybe there. Suddenly everything makes sense. I know, right? Now we can see. He's got a Swiss cheese defect on his midline. Yeah. You should be able to see your Veress needle now too. Yeah. Yeah. For a minute, I thought that we would open, I mean, not that it would be a problem, but... But he's got a sizable hernia on the midline. I mean all these are defects, I'm going to show you. I can see them better here with the robot, he's got holes you see everywhere. Yeah. So the question is, well I guess we don't have any consent to fix it. So... That was my next question. Yeah. It didn't show from the, from the clinical exam or the - yeah. Because it was all plastered up. Yeah. Yeah. It's all plastered. Yeah, exactly. Do you wanna - can you go to your Veress, so we can get it out. Yeah. Oh yes, yes, yes, yes. Absolutely. So yeah, so it was there, right? Somewhere. So we can take it out. It's good. It is good. It was... I'm sorry, what? Oh, that's the other port? Let me see what we will do now with what we have and yeah. Yeah, we'll see. Yeah. So this is our stomach. It doesn't seem like anything is happening here. We'll check everything one more time, but we're looking good so far. Okay. Here we have to find the proper plane. There is the bowel wall. Say what? You may be able to continue doing this just where we are. Yeah. Yeah. It is very possible. I can just upsize one of these for the stapler, and we should be good. Yeah. Yeah. Let's see how this will go. So this now, so this is remnant of posterior fascia. So the - yeah. So this stays up and this goes down. We will need a little precision here. I'm sorry, what? His dad, like, there's no form in his chart, but his dad's like his official healthcare proxy. He's your point of contact. His dad is his official, he never said, I mean, he's an adult, right? So we don't need a healthcare proxy. No, I'm saying... Oh, for the hernia thing? Yeah. Yeah. Let, let me see how... Roll it over in your head, okay? Yeah, yeah. Great. Thank you. Thank you. I take all this down for the only reason of having free space to work, if we need mobilization of the colon, which we'll see if we need. But so far so good. Okay. That's where the other port would come out handy, Melissa. But, let's see. I'll reverse my camera. Okay. Mesenteric border here. So a little bit more caution and, okay. Alright. Okay.

CHAPTER 5

So, let's see. Where is the other port there? It must be here. This is also adhered. That's the colon, right? This is colon, right? Yeah. Yeah. That's good. This must be the end of it. Yeah. Yeah. This is, I I think they left it on purpose. Yes. No, I know. That's what I'm trying, Lauren. But I'm trying to not create bleeding because Yeah, like this, just trying to see where I will be able to manipulate it to find tissues that are meeting each other. That's where the other port would help. 'cause I would be able to hold it. Do you have something to hold it with this? Yes. Let me see if it makes sense to work on the other side. Okay. Yeah. Hold it there. That's perfect. I think that this is now where the colon is. And we simply have to start taking with the vessel seal. Let me just go back down. Hold it there exactly As you're holding it. I you open the vessel seal? Yes, please. Okay. This is the... Time for camera cleanup and, and a breather. All right. I am reversing camera. I don't even know that I need to go that far down wherever it, I, yeah, I I just want to bring the, okay. Yeah, yeah. Alright. I can get the vessel sealer in there. Four? On four please. Yes. Thank you. Can you lift up towards the abdominal wall and away from you just push towards, yeah, there you go. That's beautiful. Thank you. Up against the side. Yeah, that's great. So not that it cuts supremely. Is it going to cut? I don't think you're doing it all way. Okay. All the way. You're not cutting all the way though. You're letting go of the cut. What? See, cut enabled, press again to cut and then release the grip. You got to do that again. Ah, what was I doing wrong? You're letting go of the pedal too soon on the cut, and then you have to click it again one more time. So yellow - yellow again. Beautiful. Is that small bowel there? But where, where was it? I don't understand. It shouldn't be bowel. It's a lymph node. It's a, it's a lymph node. No, it's a lymph node. It's, I don't think it's bowel. Yeah. Yeah. That's my bowel. And this. Thank you. Yes, we can - excellent - you can let it, you can let go. Thank you. And now this will go down and let's see this thing that we were worried about. I don't see anything there. You know what, when I take the colostomy down I will see it again. Alright, so let's check our colon here, which has plenty of length. Yeah, it looks good. It looks great. Can you insert your bowel forceps again and just grab it there. Give it a, a good grab. That's it. No need to pull it too much. I just want to create a little bit of space here for our anastomosis. No worries, no worries. Excellent. That's okay. One more time. Excellent. So I will, I'm actually going to transact here. I am going to transect right there. Okay. Okay. And - there. Okay. Can I have the stapler? I have to upsize that port. Oh, okay. Okay, then don't do it yet. Just one second. You can release that. Okay. Release it. Yeah. Go to the other side. Yeah, let, yeah, lemme just work a little bit more on the, on the colostomy in a minute. If we... Okay. I can upsize this thing once you stop working. Yeah, yeah. One second. I just want to make sure that we're okay here. We're gonna open the stapler though. Yes, yes, yes. You may open the stapler. And on this side. You want like what would be a like purple? Yes. Ready to upsize. Alright ready to upsize. Can you look at this port as best you can? Alright, do you want the vessel for right now or the stapler? The stapler.

CHAPTER 6

The sixty. You can do it George. You see that's that, that's a funny thing that indeed, as you correctly say, Lauren, in open surgery. Yeah, well the option would then be to have two staplers. Okay. We're good there? Yep. You know how to fire it? Fire. Yep. Clamp it, now press the yellow to fire, then press and hold it. And then just open it normally. Perfect. And then for me to take the stapler out, I just need you to straighten it out. Okay. I'll put this here. You want the vessel sealer back, or...? Let me just see. I will want the stapler back I think. Yeah, gimme the same. Gimme the same. 'cause if it doesn't work then Lauren will be on my case. Thank you. All right. Okay. This one will...

CHAPTER 7

Thank you. Let me have my scissors for a minute. Thank you. Can you get the bowel forceps back in? You can grab the thing that I'm holding there. That's good. Hold on that side. You can release that for a minute. Yes. If you don't mind. If you want, you can push it a little bit towards up there. I just want to... It's all so stuck. A 3-0 V-Loc and my driver. Okay. I'm gonna let go of this. Thank you. Yeah. I think we have a six and a nine as 3-0. I'm gonna come out with your scissor. The nine will do. Okay. Oh, okay. You'll give it to me from there. The 3-0. You can gimme a 2-0 if you have. I have nothing open. Oh, okay. Alright. Okay. Well let's see. Don't forget at the end to take the colon out, right? Yeah. That's what we're talking about is getting a bag to take it out. You can take that with your left hand. Thank you. Can I by the way, give you some staples from the accessory port? Yeah, yeah, absolutely. Perfect. Thank you. Hold that again? No, I'm just trying to see how I'm going to make it sit 'cause I have to maybe there if I do it like that.

CHAPTER 8

Let's see. Let me have scissors again and get your suction ready on the accessory port. So you prefer to anchor it up there rather than putting another port in and just using the third hand to hold it. I'm sorry. Yes. Just one second. I'll tell you when to suction. Don't worry. Got it. Okay. That's a big enough anastomosis here. And do you want to suction? There's not much to suction here. Just this mucus down there. Perfect. That's good enough. Excellent. Yeah. No, it's so easy to drive it on the back layer. Yeah, just suck there. Let me see. Hold on. On our last cut on both sides. Thank you. Oh, it's on the other side. Very tricky. Needle driver. Thank you. I'll see that. You see that even with the anchoring, it moves a little bit more than you would like to see it move. So that's why it is important to anchor it. Otherwise it goes all over the place. And because I do a continuous second layer, I don't pull my stitches too hard because I don't necessarily want them to squeeze too hard against the anastomosis. I mean, I don't want them to cinch too hard. I just want them as... Okay. And maybe one last one. And my reverse stitch to anchor. Want me to cut it? Not yet. Okay. This is yours, this stitch. And I'll get another one. You want another 3-0? Yeah, I'll need another three 3-0s at least. But this one you can take out. Thank you. Thank you. Sorry. Camera. Okay. You want it now? Yes, please. Thank you. Ready for the other suture? Another 3-0. Okay, I'm gonna come out with that driver. Yeah. Thank you. Needle driver. Do I need a more proximal one? Maybe, huh? Nope. No, no, I'm outside. No? I'm inside. Why am I in? Am I inside or outside here? I'm outside. That's going to be difficult but doable. All right. Three sutures coming out. I mean three sutures and one little remnant. So everything out please. Okay. That's a little remnant. And I will need one last 3-0 V-Loc. Thank you. One more V-Loc. You want that before? Not yet. Not this one. No. The anastomosis is down there, but this is all, okay, well we'll start there then. Can I have scissors? Yeah. No, let, let me have robotic scissors for a minute. Thank you. Let me have my needle holder again. Actually, just one second. Don't take it out. Don't take the scissors yet out. Okay, let me have my needle holder. George, how's it going? Ready to finish. Come on. Maybe. Alright. And the last one. Yeah, I mean there's no way things will not go there. They're already there, and I'm not gonna do anything more.

CHAPTER 9

Alright, you can have this suture, we'll do a little bit of suction and we are done. And of course we will remove this little piece that is somewhere there. Okay. There's nothing there. Let's try to see up. If there's anything to be seen, I cannot really turn my camera anymore any further up, so we may need to do it laparoscopically. Yeah, I cannot... Let's do - why don't you, I'm gonna take the spsecimen outta this one. Yeah. Yeah. Take the specimen and then we'll do a little suction and yeah. Okay. Hold on. Don't move the camera. Okay. What is this that I'm looking at, the bag? Yeah. You're going to hit the bag, right? No? The bag? No, I already got the bag out. Oh, you got the bag out. So, oh. Oh, this is me. Okay. Okay. Alright. I'm removing my clamp. You can take it out, in fact, if you want whatever you - no, leave it there. Alright. I'm looking at you. He needs a... Want me to dissect out that thing and then we'll just close it. Yeah. Dissect the... Dissect out the colostomy. And then what do you, do you want to purse-string around it and partially close it or what? You know, he does these awful scars. Yeah. So I think that - let's wash it out really well and close it. Primarily all the way? Primarily. Well do you wanna go above and I'll go below? I don't mind. Whatever you... I'll go above.

CHAPTER 10

Okay. So it'll be like this. Yeah. You just go far outside here? Yeah, I would go close. Close to the skin and I would come there. Yeah. Watch your hand. I'm gonna throw this last stitch here. There you go. And go deep, deep, deep and arrive there. Perfect. Do you wanna take the scar before you... Yeah. And let us have a Kocher clamp. That's perfect. I'll take the scissor back. Oops, sorry. And do one more Kocher clamp. Yep. And now you can go with, below that. You can go with both if you want. Knife back. Underneath you here. I'm sorry. Lauren. Yes. Can you aim a light right over here? Can you aim a light here? And if you can aim that one right where they're working. Beautiful. There you go. Keep on going. Lauren, can I get another sponge? Yeah. Thank you. You drop that one? No, no, no. He stole it. He has every right to steal it. Technically his sponge. Jut making sure... Excellent. And you have it here all the way? Yes. All the way here. What is that? Piece. It's a little... You want two gloves? You also have the LigaSure. Nah. Okay. And here. Yep. We will close it with 0 non-loop PDS. You have the whole thing there? I'm gonna come close this one for you George. Yeah. Yeah. Do you have a Schnidt? Yeah. We're all the way down there. Yeah, you can cut with confidence. Don't worry. I have my finger. Yeah. Yep. Okay. This is good. This colostomy. I mean, we don't need to send it. No, no. There is a little bleeder there or is it? So do you want to do, do you want to do two layers? Just can we have the Kocher again? One is here and the other Kocher - and put, if you want just to do two layers. So just put like a couple of figure-of-eight on the posterior layer first, which you have. And then close the... So just PDS and Vicryl, and then... PDS, all non-loop PDS on the posterior layer. And then again on the anterior layer Two layers of PDS? Yeah. Give us... And then close the skin? Yeah, yeah, yeah. I would close the skin for him because he's making such ugly scars. So let's have the PDS. So go on the posterior layer, you know, grab this, grab, grab just this first. This, okay. Yeah. Throw it there. Deep. Okay. And there. Wait, wait. Yep. Okay. Wait, because we were a little locked here. Hold on. Exactly. Yeah. No, don't, yeah. Let me see it. Okay. Can you rotate your wrist? Yes. Okay. Yep. I am afraid that, wait, wait, wait. Okay. Do you, you're going to give us another one? Do you have another one yet? Yeah, yeah, 'cause I don't think it's, yeah. I'm still gonna do that for you. Yeah, yeah. Is there anything bleeding? All right, one down. I got it. Wait. Yeah, yeah. Wait, wait, wait. All the way down to the, yeah. Sorry. Okay. And go all the way down. Yep. Perfect. All yours. Okay. So, alright. This too. You may tie this, too. Scissors again. I got it. Alright, so cut this. Yeah. What do you wanna do with the skin? Just tie those and then you will put an anterior layer. Skin, I would do a 4 - I would wash everything and I would do a 4-0 like everything else. And I would do...Oh, really, okay. What do you think? Yeah. It's high chance. Risk of wound infection's pretty big. Yeah. I think I would probably staple it, leave it open to drain. Look what - he does this. I don't know what to say. We just did a purse-string, and came up, around like, and left it, so pack it. Yeah. I mean it's going to be, yeah. Okay. Okay. Your, your fascia is there. You want to just come all the way through in one? Yeah. Come out. Come out and we'll go on the other side. Yeah. Take this. Come out there. And here your fascia is... Right there. Yeah. No, go, go deep, deep cheat it vertically. Even more like that. Yeah. Don't skive it. Yeah. Okay. Right. And one more stitch lower. And here go, go deep in here. Deep. There you go. That's it. Okay. And, all right, one more stitch. Deep. Deep. And really low down now. That's it. And deep, deep down there. Can I put this? No, no, no. Deeper, deeper in, and end up more laterally. Like this? Here. Here, right there. Hold on, hold on. Right there. Here? Yes. And good. Okay. Alright. Okay. I'm gone.

CHAPTER 11

So as expected, this patient had a lot of adhesions. We struggled to create space initially to find a place to place our robotic ports. So we had to do a lot of the initial adhesiolysis laparoscopically until we freed up the abdominal wall in places where we could place our robotic ports and eventually dock the robot and continue the rest of the operation robotically. Obviously postoperatively we expect an element of paralytic ileus because of the extensive manipulation of the intra-abdominal contents during the adhesiolysis I expect that this patient may spend a few days in the hospital. I hope that pain control will be adequate, and we will try to proceed as quickly as possible with fluid and food for as long as the patient's nausea is managed appropriately and he starts having some gas. Overall, I expect that the recovery will be fine despite the difficulty because of the adhesions of the operation. Otherwise it was uneventful, and I think that the patient will do very well.