Derby Pancreaticobiliary & Robotic AWR Unit
@DerbyPBunit • 11,662 subscribers
Pancreaticobiliary, Adv Lap/Robotic & Robotic AWR Unit @UHDBTrust | Operative Videos & SurgEd | Department Leads @altaf_awan12 & @ib9994
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𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙍𝙚𝙥𝙖𝙞𝙧 𝙤𝙛 𝙋𝙚𝙧𝙛𝙤𝙧𝙖𝙩𝙚𝙙 𝘿𝙪𝙤𝙙𝙚𝙣𝙖𝙡 𝙐𝙡𝙘𝙚𝙧 𝙬𝙞𝙩𝙝 𝙋𝙧𝙞𝙢𝙖𝙧𝙮 𝘾𝙡𝙤𝙨𝙪𝙧𝙚 & 𝙊𝙢𝙚𝙣𝙩𝙖𝙡 𝙋𝙖𝙩𝙘𝙝 Presentation: 🔵1 day history of sever upper abdominal pain 🔵Smoker and excess ETOH 🔵CXR ➡️Pneumoperitoneum 🔵CT ➡️Perforated duodenal ulcer 🔵Time from ED➡️theatre 3 hours Operative Approach: 🔴Thorough peritoneal lavage ➡️Lap washout allows for thorough removal of intra-abdominal contamination ➡️Modern OR table tilting can provide better view then open in select cases 🔴If fragile tissue then omental patch only ➡️This approach is a modified version of Grahams patch repair ➡️When suitable, we prefer primary closure with patch after 🔴For large perforations kocherisation of duodenum may be indicated 🔴Convert to open if: ➡️Large ulcer ➡️Associated ulcer bleed 🔴H. Pylori eradication therapy on discharge 🔴OGD in 6-8 weeks to confirm healing Key Points: 🟢Timely intervention critical 🟢Lap approach in EGS should be encouraged 🟢Compared to open, advantages of lap are: ➡️Reduced pain ➡️Reduced LOS ➡️Reduced incisional hernia rate 🟢Trainees should be exposed to lap EGS early to develop skills and confidence #FOAMed #GITwitter #MedEd #SurgEd #EGS #SoMe4Surgery
Derby Pancreaticobiliary & Robotic AWR Unit394,064 views • 2 months ago
0:38
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𝙀𝙢𝙚𝙧𝙜𝙚𝙣𝙩 𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙄𝙣𝙛𝙧𝙖𝙘𝙤𝙡𝙞𝙘 𝙉𝙚𝙘𝙧𝙤𝙨𝙚𝙘𝙩𝙤𝙢𝙮 Patient Selection: 🔵Central, infracolic collections that are dominantly solid (WON) often not amenable to perc. drainage and/or narrow window of access for transgastric approach 🔵Too unwell for concomitant cystjejunostomy 🔵Septic 🔵3-4 weeks into acute attack of SAP Approach: 🔴Initial identification of bulge in transverse mesocolon 🔴Location confirmed with IOUS 🔴Window created into infracolic compartment 🔴Necrosectomy and washout performed 🔴2 x 18F Robinsons drains placed adjacent to cyst Key Points: 🟢Timing of intervention critical 🟢Surgical approach allows 𝘀𝗶𝗻𝗴𝗹𝗲 𝘀𝘁𝗮𝗴𝗲 𝗰𝗹𝗲𝗮𝗿𝗮𝗻𝗰𝗲 of WON which avoids multiple hits of sepsis 🟢Concomitant cholecystectomy can be undertaken in select cases 🟢Patient selection and discussion in benign specialist MDT key Link to our paper in Journal of Gastrointestinal Surgery (JoGS) below: #FOAMed #GITwitter #surgery #SoMe4Surgery #MedEd #hpb
Derby Pancreaticobiliary & Robotic AWR Unit193,252 views • 1 month ago
Robotic Longitudinal Pancreaticojejunostomy 🔵Chronic pancreatitis secondary to ETOH excess - now teetotal 🔵Multiple admissions with chronic pain 🔵Significant impairment on QoL 🔵2 emergency admissions ➡️Acute pancreatitis with side branch disruption 🔵Normal LFTs 🔵CT/MRCP ➡️Dilated PD with "chain of lakes" ➡️Non-obstructing stone at HOP 🔵MDT ➡️Decision to proceed to surgery 🔴Adjuncts such as IOUS, ICG and intraoperative pancreatoscopy ➡️Improves operative safety ➡️Promotes learning and training in complex benign PB conditions 🔴Benefit of ICG ➡️Visual confirmation of splenic artery and proximity to PD/pancreatic parenchyma #FOAMed #MedEd #surgery #hpb
Derby Pancreaticobiliary & Robotic AWR Unit106,167 views • 22 days ago
Emergency Laparoscopic Repair of Strangulated Femoral Hernia with Small Bowel Resection & ICG 🔴Reduction of small bowel ➡️Await perfusion recovery ➡️Allows for demarcation of ischaemic segment 🔴Undertake hernia repair ➡️TAPP approach ➡️Opted for suture repair for this case ➡️Biologic mesh alternative option ➡️Synthetic mesh can be considered if no bowel resection 🔴ICG to assess bowel perfusion and delineate length of resection ➡️Given intraop at time of assessment ➡️Immediate assessment within 30 seconds key ➡️Excellent tool for teaching trainees 🔴Advanced lap skills crucial 🔴Lap EGS recommended ➡️Underutilisation in the UK
Derby Pancreaticobiliary & Robotic AWR Unit117,305 views • 2 months ago
3:55
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𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗧𝗿𝗮𝗻𝘀𝗴𝗮𝘀𝘁𝗿𝗶𝗰 𝗡𝗲𝗰𝗿𝗼𝘀𝗲𝗰𝘁𝗼𝗺𝘆 𝗮𝗻𝗱 𝗖𝗼𝗻𝗰𝗼𝗺𝗶𝘁𝗮𝗻𝘁 𝗖𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆 𝘄𝗶𝘁𝗵 𝗜𝗖𝗚 Preoperative Workup: 🔴Preoperative CT imaging ➡️Retrogastric WON ➡️Portal HTN with evidence of portocavernous transformation 🔴Preoperative MRCP ➡️Help distinguish % of necrosis vs. liquid similar to EUS 🔴Symptomatic pt with no evidence of ongoing infection ➡️Suitable for single stage MIS Surgical Approach: 🟢IOUS essential to identify locality of WON 🟢Anterior gastrostomy 🟢Necrosectomy performed ➡️Single stage clearance of WON ➡️EUS requires multiple sessions with recurrent hits of sepsis between interventions ➡️Visual feedback critical in 🤖 due to lack of haptic feedback 🟢Haemostatic agents applied into cavity 🟢Cystgastrostomy maturation ➡️0 Vicryl suture in figure of 8 ➡️Prefer over stapler due to haemostatic benefit of suturing 🟢Two layer closure of anterior gastrostomy 🟢Subtotal cholecystectomy ➡️Fused hepatocystic triangle ➡️Increased difficulty in performing cholecystectomy early in severe acute pancreatitis Benefit of 🤖: 🔵Improved views of WON cavity ➡️3D enhancement 🔵Wristed instruments ➡️Better articulation for suturing of cystgastrostomy #FOAMed #GITwitter #MedEd #SoMe4Surgery #Robotics #Pancreatitis #surgery
Derby Pancreaticobiliary & Robotic AWR Unit16,601 views • 10 days ago
Tips & Tricks for Minimally Invasive Adhesiolysis 🔴Gentle counter traction on bowel whilst scissors dissects adhesion under tension 🔴Cold scissors 🔴Divide adhesion close to abdominal wall 🔴Include tissue from abdominal wall onto bowel ➡️Shown prior to division of adhesion
Derby Pancreaticobiliary & Robotic AWR Unit95,516 views • 9 months ago
2:06
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𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗧𝗔𝗣𝗣 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗥𝗲𝗰𝘂𝗿𝗿𝗲𝗻𝘁 𝗥𝗶𝗴𝗵𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 Patient Presentation: 🔵Previous open repair 🔵Mesh in preperitoneal plane 🔵Referred with painful recurrence Surgical Approach: 🔴Medial recurrence 🔴Near complete mesh excision ➡️Small disc on abdominal wall side left to avoid nerve injury 🔴Transversalis fascia approximated with V-loc ➡️Imbrication of transversalis fascia ➡️Thin bites only ➡️Movement facilitated by 🤖 🔴Mesh ➡️Good medial coverage #FOAMed #GITwitter #Hernia #Robotics #MedEd #SurgEd
Derby Pancreaticobiliary & Robotic AWR Unit33,131 views • 3 months ago
𝗘𝗺𝗲𝗿𝗴𝗲𝗻𝗰𝘆 𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗟𝗲𝗳𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 𝘄𝗶𝘁𝗵 𝗜𝗖𝗚 Surgical Approach: 🔴Initial assessment of small bowel with ICG 🔴Small bowel placed in pelvis with warm wet swabs overlying 🔴TAPP approach to hernia repair ➡️Critical view of MPO ➡️ICG to help delineate key structures ➡️Progrip mesh ➡️3-0 absorbable V-lock to close peritoneum 🔴Reassessment of small bowel after hernia repair ➡️ICG present in bruised area demonstrating viability ➡️Aided decision making to not resect or oversew Robotics in EGS: 🟢Case selection key 🟢MDT approach with anaesthetic and scrub teams to coordinate 🟢Minimally invasive approaches in EGS should be encouraged #FOAMed #GITwitter #MedEd #Surgery #Hernia #EGS
Derby Pancreaticobiliary & Robotic AWR Unit23,643 views • 2 months ago
Principles of Szabo Knot 🔴Square knot - 2 throws 🔴Slip knot - unlock by pulling in opposite directions 🔴Slide - non-closed grasper 🔴Lock 🔴Final throw Useful in: 🟢Tissue approximatiob under slight tension 🟢Deep areas i.e. OG hiatus, pelvis #MedEd #SurgEd #surgery
Derby Pancreaticobiliary & Robotic AWR Unit46,561 views • 5 months ago
2:20
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Laparoscopic Infracolic Necrosectomy and Drainage of RIF Abscess 🔴Septic patient but no organ failure 🔴Narrow window of access for EUS or IR drainage 🔴Single stage clearance of WON and drainage of RIF abscess ➡️Prevents hits of sepsis between multiple procedures ➡️Address both collections at once ➡️Select cases ➡️Benign PB MDT ➡️"One size does not fit all" Our paper on infracolic approach in Journal of Gastrointestinal Surgery (JoGS): Our collaboration with BehindTheKnife on MIS for complicated SAP: #Surgery #HPB #Pancreatitis
Derby Pancreaticobiliary & Robotic AWR Unit24,356 views • 3 months ago
2:06
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𝙀𝙢𝙚𝙧𝙜𝙚𝙣𝙘𝙮 𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙍𝙚𝙥𝙖𝙞𝙧 𝙤𝙛 𝙎𝙩𝙧𝙖𝙣𝙜𝙪𝙡𝙖𝙩𝙚𝙙 𝙁𝙚𝙢𝙤𝙧𝙖𝙡 𝙃𝙚𝙧𝙣𝙞𝙖 𝙬𝙞𝙩𝙝 𝙎𝙢𝙖𝙡𝙡 𝘽𝙤𝙬𝙚𝙡 𝙍𝙚𝙨𝙚𝙘𝙩𝙞𝙤𝙣 𝙖𝙣𝙙 𝙄𝘾𝙂 Surgical Approach: 🔴Reduce small bowel first ➡️Gentle abdominal pressure and squeeze ➡️Atraumatic grasper to hold bowel and gently manipulate ➡️Stretch hernia ring if needed ➡️Gentle side-to-side traction without grasping useful when bowel is fragile 🔴Perform hernia repair ➡️Suture repair safe option in strangulated small bowel requiring resection ➡️On rare occasions a biologic mesh may be an option ➡️Synthetic mesh could be considered if no resection involved 🔴ICG to assess bowel perfusion and assist in delineating length of resection ➡️Improve trainee understanding of key concepts ➡️Reduce risk of leak or stricture ➡️"See the invisible" 🔴Advanced laparoscopic skills critical 🔴Training and development of laparoscopy in EGS should be encouraged #FOAMed #GITwitter #MedEd #Hernia #Surgery #SoMe4Surgery
Derby Pancreaticobiliary & Robotic AWR Unit173,995 views • 3 years ago
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"Hot" Laparoscopic Cholecystectomy: 🔴Principles remain the same 🔴Know bailout options ➡️Subtotal 🔴Gallbladder decompression 🔴Rouviere's important landmark 🔴Endo pledget very useful in these cases 🔴Suction/irrigation ➡️Blunt dissection 🔴Demonstrate CVS #FOAMed #GITwitter #surgery #SoMe4Surgery #MedEd #chole
Derby Pancreaticobiliary & Robotic AWR Unit21,931 views • 3 months ago
𝗦𝘁𝗼𝗻𝗲 𝗥𝗲𝘁𝗿𝗶𝗲𝘃𝗮𝗹 𝗳𝗿𝗼𝗺 𝗡𝗮𝗿𝗿𝗼𝘄 𝗖𝗵𝗼𝗹𝗲𝗱𝗼𝗰𝗵𝗼𝘁𝗼𝗺𝘆 🔴Bring CBD stone trapped in basket to choledochotomy site 🔴Remove scope over wire 🔴Keep tension on basket wire with trapped CBD stone 🔴Introduce choledochotome (or laparoscopic scissors) and minimally extend choledochotomy over large CBD stone ➡️Prevents large choledochotomy #FOAMed #GITwitter #MedEd #SoMe4Surgery #Surgery
Derby Pancreaticobiliary & Robotic AWR Unit38,724 views • 6 months ago
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Our Approach 🔴Dissection was kept close to gallbladder throughout 🔴Arterial rather than venous bleed 🔴Bleeding brisk ➡️Pressure did help but not successful 🔴Small arterial branch identified entering GB wall 🔴Suction/irrigation handy 🔴Careful evaluation of bleeding vessel 🔴After confirmation, clip applied to the vessel that was entering GB ➡️Likely a small branch off RHA 🔴Venous bleeds more common and can be a significant challenge intraoperatively Many thanks for all the engagement with the post 👏🏽
Derby Pancreaticobiliary & Robotic AWR Unit32,944 views • 7 months ago
Tips for Retrieval of CBD Stone during Transcholedochal LCBDE 🔴CBD >8mm 🔴Atraumatic graspers useful 🔴"Milking" CBDS 🔴5mm choledochoscope with 0-Tip basket ➡️Gentle "to-and-fro" motion ➡️Irrigation 🔴Withdraw choledochoscope over basket wire with trapped CBDS 🔴Extend choledochotomy #FOAMed #GITwitter #Surgery #SoMe4Surgery #HPB
Derby Pancreaticobiliary & Robotic AWR Unit29,314 views • 7 months ago
Laparoscopic Ileocaecal Resection with Intracorporeal Anastomosis and ICG Patient Presentation: 🔴Sudden onset severe abdominal pain 🔴Tender abdomen 🔴No previous abdominal surgery 🔴High WCC 🔴Lactate ➡️5 on arrival down to 2 in 2 hours following fluid resuscitation 🔴CT abdomen/pelvis ➡️Red arrows show no small bowel perfusion with mural thickening ➡️Green arrows show perfused small and large bowel ➡️Mesenteric vessels patent Surgical Approach: 🔴Lap EGS approach ➡️Torsion of small bowel with Meckel's adhesion to abdominal wall acting as pivot point ➡️80cm ischaemic small bowel involving ileocaecal junction 🔴Specimen retrieved via extension of LUQ 12mm port
Derby Pancreaticobiliary & Robotic AWR Unit18,311 views • 5 months ago
2:05
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1:49
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𝗧𝗿𝗮𝘂𝗺𝗮 𝗟𝗮𝗽𝗮𝗿𝗼𝘀𝗰𝗼𝗽𝘆 𝗮𝗻𝗱 𝗣𝗿𝗶𝗺𝗮𝗿𝘆 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗦𝗺𝗮𝗹𝗹 𝗕𝗼𝘄𝗲𝗹 𝗜𝗻𝗷𝘂𝗿𝘆 Presentation: 🔵Presented 6 hours following football tackle with knee to abdomen 🔵Resulted in blunt trauma to anterior abdominal wall 🔵On examination ➡️tender abdomen with tachycardia but normotensive and HB stable 🔵CT in ED ➡️Small volume intraperitoneal free air anterior to liver ➡️Gas locules around transverse colon at the splenic flexure 🔵Direct transfer from ED to OR Approach: 🔴Low threshold for laparoscopy +/- proceed 🔴Complete examination of small bowel on both anti mesenteric and mesenteric sides 🔴Two areas of injury immediately beyond DJ flexure ➡️One full thickness ➡️One seromuscular 🔴Free intraperitoneal bile an irritant 🔴Primary repair with 2/0 vicryl ➡️If concern regarding ischaemic edges option to freshen prior to closure 🔴Thorough peritoneal lavage 🔴Advanced lap experience critical #FOAMed #GITwitter #trauma #SoMe4Surgery #surgery #MedEd
Derby Pancreaticobiliary & Robotic AWR Unit64,430 views • 2 years ago
2:38
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𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗖𝗼𝗺𝗺𝗼𝗻 𝗕𝗶𝗹𝗲 𝗗𝘂𝗰𝘁 𝗘𝘅𝗽𝗹𝗼𝗿𝗮𝘁𝗶𝗼𝗻 𝗣𝗼𝘀𝘁 𝗖𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆 Patient Presentation: 🔵Previous cholecystectomy 🔵2 previous ERCPs 🔵Recurrent large stone ➡️1.7 x 1.1 cm ➡️Failed endoscopic clearance ➡️+/- requirement for EHL 🔵MDT decision to proceed to bile duct exploration Surgical Approach: 🔴Careful dissection of adhesions in the GB fossa to expose the CBD 🔴ICG injected immediately following induction of anaesthesia 🔴Firefly mode used to confirm the CBD 🔴Vertical choledochotomy made with robotic shears 🔴Large stone extracted by milking it gently through the choledochotomy 🔴Check choledochoscopy to confirm clearance of the CBD 🔴Closure of the CBD with 4/0 Vicryl Benefit of Robotic Platform: 🟢Wristed instruments which improves ergonomics for suturing 🟢May reduce the learning curve for transductal CBDE when compared with laparoscopy
Derby Pancreaticobiliary & Robotic AWR Unit13,622 views • 4 months ago