- 2 days ago
Dr. R.K. Mishra's Personal Meeting Room
https://www.laparoscopyhospital.com/SERV01.HTM
https://www.laparoscopyhospital.com/SERV01.HTM
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LearningTranscript
00:00Okay, now go to the CRS screen and go to advanced, go to second character, share, share,
00:30share, share, share, share, share, share, share, share, share, share, share, share, share,
00:43share, share, share, share, share, share, share, share, share, share, share, share, share,
00:48share, share, share, share, share, share, share, share, share, share, share, share, share,
00:55share, share, share, share, share, share, share, share, share, share, share, share, share,
00:56I can't keep the same.
01:05I can't keep the same.
01:11It's my own identity.
01:13It's my own identity.
01:15It's my own identity.
01:25Stop share.
01:31Virtual background is still loading.
01:35Use video
01:37or don't use video.
01:39Start video anyway.
01:51Can you see both the camera is showing?
01:55Integrated webcam.
01:57Cam link.
01:59Okay.
02:01Don't do that.
02:03Go to share screen again.
02:07Go to advance and then share.
02:09There is a month ofix.
02:11In advance.
02:13Share.
02:15Share.
02:17Share.
02:19Share.
02:21Share.
02:23Share.
02:25Share.
02:27Share.
02:28Share.
02:29Share.
02:31Share.
02:33So, he is putting that into a key job, I'm like this.
02:53I thought for you.
02:54Thank you very much.
03:25Okay.
03:27Now, let's see.
03:28Can you see?
03:29I'm going to see.
03:31Can you see?
03:32Are you there?
03:33Share your screen?
03:34I don't know.
03:35Share your screen.
03:36Share your screen again?
03:37Go to share your screen again.
03:41Advanced screen.
03:42Again, share.
03:43See?
03:44See?
03:45Okay.
03:46Yeah.
03:47Okay.
03:48Just try to give one more
04:18So we can see here that pressure pressure is 15 and actual pressure is going 12 So slowly we can see here that within 300 ml it became double digit
04:46If it is double digit that means we have to re-interview
04:54So within few seconds it should become single digit
05:12Now we will start the flow
05:16Keep it lifted a little bit
05:26And now it is okay
05:30Chandan
05:34You can bring the camera
05:38You can bring the camera
05:40You can bring the camera
05:42She is a little obese
05:58Can I have the gas
06:06Now you can see it is one
06:18Still trying to go double digit
06:20But it could be due to the initial
06:26Now the A
06:28That means 5
06:30Yes, we will do it
06:36How do you do it?
06:38How do you do it?
06:40How do you do it?
06:42Take care
06:44Thank you
06:46Take care
06:48Take care
06:58Now we may increase the flow rate
07:02At the moment
07:04At the moment
07:06of the time
07:08you can see it
07:10You can see it
07:12I can see it
07:14I can see it
07:16How do you do it?
07:18How do you do it?
07:20I can see it
07:22I can see it
07:24So, initially, if little gas has gone to the pre-patronium, then you should increase the
07:52pressure to the 18.
07:55That will be good idea because it will take all the gas which has gone in the pre-patronium
07:59out.
08:00You can see there is a homogenous distension all around.
08:04That means it is okay.
08:07And then, you can see the speed of the speed of the camera.
08:28so now we will take the gas out and enlarge the decision
08:42it should be enlarged to
08:4711 mm. Once it is 11 mm, then we can dilate the bitlo-intestinal tract
09:12then the car should go perpendicular
09:26this is hissing sound
09:31now you will attach the tubing of the interpolator
09:42and then we will start the flow and increase the flow rate to 10 liter per minute
09:58so we are in
10:20so you see the uterus here you see the round ligament
10:44this is the barbell
10:52first you should inspect just below your entry point
10:56for any inadvertent injury
11:00after that we will go here
11:06we can see this is the
11:08stomach
11:10so now we will
11:12put the other port
11:14later I will show you diagnostic also
11:16but first let us start
11:18and put the other port
11:20just below
11:22you can log into with your own account
11:26don't use this wifi
11:28just you use your own mobile data
11:32have a look
11:36so
11:38this is the second port
11:40just below the GPS turnerm
11:42and it is left
11:44and initially we have to go perpendicular
11:52like that
11:54like that
11:56and then we should pierce the membranous part of
12:06falsiform ligament
12:08this is the second port
12:12that will be mid clavicular line
12:16just below the coastal margin
12:38the fourth port
12:40should be 7.5 cm latcher
12:44and 7.5 cm below the third port
12:46after that you will take a grasper
13:02head up
13:06head up, right up
13:08position of the percent
13:10will be changed
13:12to head up and right up
13:18and we will take one grasper
13:28first we will do a little diagnostic
13:30we are pushing it
13:32we are pushing it
13:34down and lifting that
13:36lifting it like that
13:42and then take a grasper
13:48and you will go
13:52and catch the fundus
13:54and you will go
13:56and catch the fundus
13:58and you will retract it
14:02and you will retract it
14:04towards the shoulder
14:06take care that
14:08like this
14:10take care
14:12now a traumatic grasper
14:14so we have to be careful
14:24that this grasper should not
14:26push the stomach
14:28the center
14:34the center
14:36center
14:38my screen
14:40rotate
14:42yes this is good
14:44so we are all set to go
14:46so we are all set to go
14:48harmonic
14:52so we can see this is in front of us
15:06this is the Rovier sulcus
15:08that is called Rovier sulcus
15:10that is called Rovier sulcus
15:12don't speak
15:14otherwise
15:16don't speak
15:18especially here
15:20especially here
15:22we have given
15:24andromedial traction
15:26and this is called Rovier sulcus
15:28so always your dissection should be
15:30above the Rovier sulcus
15:32if you are below the Rovier sulcus
15:34if you are below the Rovier sulcus
15:36if you are below the Rovier sulcus
15:37you are in trouble
15:38so this is Rovier sulcus
15:40here
15:41and here is the CBD
15:43this is CBD
15:44this is cystic particle
15:46so first we will start dissecting
15:48the posterior peytonium
15:50so this is the posterior peytonial dissection
15:55which you should start
15:57which you should start
16:11take care that it should not nears the lever
16:15and this is the peytonium
16:17which you will separate
16:19only peytonium
16:21you don't be in front
16:47so that they will see that
16:50they will see that
16:52so all of them can see that
16:56everyone is seeing
16:58everyone is seeing
17:00now we will do the anterior dissection
17:10now we will do the anterior dissection
17:12and then we will do the anterior dissection
17:22only peytonium
17:24you should not cut anything except peytonium
17:28you should not cut anything except peytonium
17:30you should not cut anything except peytonium
17:32you should not cut anything except peytonium
17:42okay start okay
17:44if someone has mobile
17:46they can see the surgery on their mobile also
17:48you should not be able to cut anything except peytonium
17:50but they can see the surgery on their mobile also
17:52but they are here
17:54So this all is peritoneal dissection, no vessel, no any artery,
18:20this is done, now we will take a Mary line and we will do some posterior and interior window.
18:49Now keep the convexity of the Mary line towards the lever and we will make a posterior window.
18:56This is posterior window, this is posterior window and after that we will go like that
19:08and this is the interior window. Two window is formed, here is archery and this is duct.
19:15Now we will do ICG mode and you will see the CBD.
19:22ICG mode, keep it stable. Yes. So we can see here, this is ICG, here we can see this is the common hepatic duct.
19:32Can you see that? This is CVD and this is what? Cystic duct. These are nothing.
19:39You can just break it like that. This may be the artery of the cystic duct. So it is done.
19:47So this is beautiful ICG mode and it can show you this is the artery and this is which window? Posterior.
19:56This is posterior. This is which window? Anterior. So this is critical view of safety.
20:02Which is, this is what? Posterior. And here is the Kota Hepatitis. Can you see that?
20:08And this is what? Common Hepatic duct. This is common Hepatic duct. So this is over.
20:15Now tell me you want to see what? Knotting, suturing or clipping? Knotting. Knotting.
20:24Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. Knotting. K
20:54this bariatric surgery, you will find the pylorus. This is called pre-pyloric vein.
21:00You got it? And from here, you will calculate the six centimeters to do sleeve gastrectomy.
21:06So, this is just incidental findings I have shown you. So, this is the CBD here. This is
21:14a common hepatic duct. If you go very near up, this is right and left duct. This is the right
21:22and left hepatic duct here. This is right and here. This is artery. This is artery. 75% of the time,
21:30right hepatic artery is posterior to the common hepatic duct and then it gives the cystic artery
21:36and this is cystic duct. So, if again this side, we will see this is posterior window
21:42and this is anterior window, right? And the inferior surface of the liver, this is inferior
21:48surface of the liver should be visible. So, now we are ready to tie the knot
21:56and you will take it. One suture.
22:00One suture. So, ICG is very safe. Anika, it is coming there? Yes, sir, it's coming.
22:12So, if someone is chatting, this is coming there.
22:19And this is your suture. After that, you can introduce this suture into this like that. Here
22:34you go. And then come out. Again, catch the suture and feed it. Clipping is very easy. So, I will show
22:44you, some people were trying to see clip. So, I will show you the clipping for artery and knotting for the tuck.
22:55So, four times we are just trying to feed it and then you can catch it here
23:03and you can catch the tail and pull the tail out. You see the knot already, you know that how to do.
23:15You have already practiced also.
23:17So, now I will show you how to tie Masra's knot.
23:33So, here you solder is about the longer and then always go from below up.
23:54So, this is single hitch. This is first wind.
23:58This is second wind. This is first lock. This is second wind.
24:09This is second lock.
24:19After that, this is third wind.
24:20And this is second lock.
24:31And this is second lock.
24:35And now you will slide it.
24:41So, the telescope is a little dirty, we will keep it inside the flask to just clean it.
25:07So, now it is there.
25:30So, now it is there.
25:32So, now we will go near it.
26:01And first you go away so that your suture should not come and not make a jungle.
26:11And then here you go.
26:13It is done.
26:15Only one knot is more than sufficient.
26:21It is over.
26:22This is what a loop you are seeing in front.
26:24It is not a part of the knot that is not a part of the knot.
26:28That is just a loop.
26:30Because of suture.
26:44It is done.
26:45So, now we can use a clip.
27:01And we can apply one clip over the artery.
27:06So, we will go like this.
27:11You take the artery and then you will clip it.
27:14And at that time, Faruk is showing very nicely.
27:17Your tip of the telescope should be, the light cable should be at 7 o'clock position.
27:24So, it can see both the limb.
27:28Now, you can take one more clip.
27:32And you can apply that clip.
27:33On the distal aspect.
27:44So, that it will not leave.
27:50It is done.
27:52Then you can cut it with the harmonic.
27:54It will not be necessary to apply the second knot.
28:04Only one knot is more than sufficient.
28:13And see here, I will show you.
28:16You see the tail of the knot?
28:18It is quite strong.
28:23It won't come out.
28:25If you are seeing this loop, don't be disappointed.
28:29I will show you.
28:31See this.
28:33Dumbbell.
28:33Can you see the dumbbell?
28:35Concentrate on the dumbbell.
28:37It won't come out.
28:38Now, we will cut the artery.
28:40Now, it is over.
28:50After that, we have to separate it.
28:54And for that, entromedial, entrolateral, entromedial, entrolateral traction is required.
29:00Right now, which traction it is?
29:02Entromedial.
29:03Entromedial.
29:04And first, you must cut the shoulders.
29:07First of the table, please.
29:10These are the phytonium of the soldered phytonium.
29:17And then, this is entromedial.
29:20Time to time, we should try to relocate our...
29:26This person is little obese.
29:30So, you have little fatty liver.
29:32This is a panoramic lelo.
29:39Yeah.
29:39This is a panoramic lelo.
29:40It's a panoramic lelo.
29:41This is a panoramic lelo.
29:42Yes.
29:43Mother, it's a panoramic lelo.
29:47That's a panoramic lelo.
29:51Now the light cable will be down because of the internet connection.
30:21Now turn it down and then you can see it from above.
30:51Now turn it down and then you can see it from above.
31:21Now we should remove the fundus glasper.
31:34The fundus glasper should be removed so that your fraction will be better because once
31:50you reach near the fundus, an assistant is already pulling the fundus, then it will be more difficult.
32:27Now we will give traction towards the appendix that is on the right iliac posa.
32:34Now you can see it from above.
32:41Now you can see it from above.
32:43Now you can see it from above.
32:44Now you can see it from above.
32:50Now you can see it from above.
32:51Now you can see it from above.
32:57So we are cleaning the telescope little bit.
33:04We are cleaning the telescope a little bit, quiet that
33:25is, you can take a vitadine and you can rub it.
33:53And now this is the last part, before doing the last part, we should have a final look.
34:06This is the final look.
34:07So we will put the ICG mode again on, we will have a look, and this is cystic duct, this
34:14is CVD, and there is no duct of plus card, no any cystohepatic duct, and then remove
34:21the ICG mode, and then we will have final cut.
34:28So it is over.
34:35So it is over.
34:43After that, you will take a claw for a sip.
34:50After that, you will take a claw for a sip.
34:57Now you will take a claw for a sip.
35:05Now you will take a claw for a sip.
35:12And claw for a sip to hold the clip in between the jar.
35:20This is the cleaning of the telescope is very important.
35:27We should not give transverse arrest.
35:29We should hold it longitudinally and then bring it into the canola and then bring the canola
35:35also out, it is out.
35:50It is out.
36:05and there is no any malignancy risk then what we should do we should cut it with a knife
36:17longitudinally and immediately put a suction and suck it and then it will come out it is out
36:31you should clean it now i will show you
36:39the this is inside it is okay no bile no blood now we will transfer one
36:46put here
36:51head down
36:53So we will put one in the telescope, we will put one stone holding corset, it could be
37:23a stone holding corset will act as an obturator, you can leave it there, it will stay, any
37:50port which you don't want to use, you can use it.
37:54Now I will show you for gynecologist, so we will see the diagnostic, don't move, the statue.
38:10One e-traumatic claspers.
38:11One e-traumatic claspers.
38:17With.
38:18One e-traumatic claspers.
38:24you have to push it off like that
38:51cycle momentary cycle momentary this is cycle momentary here this patient has polycystic ovary
38:59although although she don't want drilling otherwise we would have done this is your
39:06round ligament here and this is deepening this is deepening so this is called triangle of doom
39:15the apex of the triangle of doom is deepening medial boundary is round ligament and laterally
39:23samsung artery and in the male there is vast difference which is not there this is external
39:28iliac artery here will be external iliac vein so this is this is very dangerous triangle if you do
39:35something wrong here it can injure this is triangle of pain here you have two knob one is lfcn other is
39:44gfn and this has laterally in vinyl ligament and medially aspermatic vessel so this area is also
39:51risky and here is called trapezoid of disaster here avarant obturated vessel and coronamortis vein is
39:59there avarant obturated vessel is a branch of inferior apigastic this is inferior apigastic turn the light
40:06cable down i will show you in pfc here is the inferior apigastic this is the here this is going in pfc here
40:17this is the inferior apigastic person and here it will be avarant obturated vessel
40:24this is important this is called medial umbilical ligament medial umbilical ligament is obliterated
40:32umbilical artery this one this is median this is
40:40median median umbilical ligament and this is the medial umbilical ligament of other side
40:47and this is inferior apigastic vessel can you that here is the inferior apigastic vessel of the left side
40:53so this is medial this is median and this is medial and this is lateral now light cable up
41:00if you see in the uterus this is the uterus and here is the uterus sacral ligament and these are
41:06uterine hump either side either side if you see here this is ip ligament this is ip ligament and when
41:14we lift it we can lifting the ip ligament this is ip ligament and just below the ip ligament you can
41:23push it here is ureter can you see the pistalsis you see ureter going this is ureter and just below the
41:33ureter is here is the internal area and above is external area below can you see the pulsation
41:43that is internal area and this is external area and ureter crosses at the pace where internal
41:49iliac and external iliac and external iliac is bifurcated so this is this anatomy this is other
41:56side this is other side this we will lift the ip ligament here is the sigma column sigma column and
42:04lifting it here is the ureter you see that ordinary just keep it there and this is left side ureter
42:12so there are nine important structure in the pelvis which you must be careful three false ligament three
42:20true ligament and three dangerous area first false ligament is median that is this is median then
42:27medial and then lateral three true ligament is one inguinal and here is a cooper medial is why
42:33important in between the medial this this entire area is bladder this all is bladder bladder bladder
42:40this all is bladder and cooper will be here cooper in pectopexy if you have to go to the cooper you
42:46should mobilize the medial umbilical ligament more immediately and then only you can go to the cooper
42:51and three dangerous area is triangle of doom triangle of pain and trapezoid of disaster so now this is
42:59the cecum and here is the appendix can you see that this is appendix this is appendix here and below is the
43:08the urator here is the urator here is the urator this one here is the urator this one
43:13this is the cimbrial end of the tube has a lot of affinity with the urator
43:17with the urator this is always there this is can i see that
43:36and this is now this is appendix here is the ccd cable this is the cecum and here is the ascending
43:45colon you see ascending colon you see ascending colon end up this is what we have removed this is the
43:53the stomach and here is what this is distended stomach this happens sometimes if it distended this is
44:04so thank you very much for watching the video please go to the lab and lunch and after lunch
44:21we will have the tumble square now so thank you very much thank you everyone who is watching on the youtube
44:27thank you
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