I think it's sort of like.
I'm delighted to introduce Richard when he loves hit Hitler has been.
So how pronunciation is right? Richard is an upper GI surgeon.
He qualified from Rotterdam in the Netherlands and then he he did a Ph.D., which was awarded with honour.
And he was a resident in Rotterdam.
There's a lot of his surgical training, and then he was a fellow in surgical oncology in Amsterdam, the academic medical centre.
Then he was appointed surgeon at the University Medical Centre in.
And has been a full professor of GI oncology and programme group leader in 2009 and in 2015, he became head of surgical oncology in Italy.
He has a very exciting programme, mainly focussed on minimally invasive interventions and robotic surgery.
As you know, we have an expanding programme here in Oxford, which we've had for 10 years,
and it's infiltrating all specialities, which I'm delighted about.
He's also got the just speaking to him very briefly now.
He's got an exciting programme on surgical imaging and also doing genetic profiling.
He's authored a small number of 308 articles and 10 chapters.
He's got many esteem indicators.
He's president of many associations, community members, etc. And I won't take more time, which is we are delighted to have you.
Thank you very much for sharing your experience with us. Thank you very much.
Thank you very much for this very kind introduction and the invitation of Nick Maynard's and his team has Box,
who is a fellow with us, and I think the Oxford Dutch Connexion is is is getting stronger and is getting better as he looks here.
And then also some other colleagues from the Netherlands,
and we talked yesterday about getting a joint meeting maybe next year or the day after which the Jewish versions of the Netherlands and the UK.
And I think it would be fantastic. So looking forward to that.
What I like to show you is our experience in them with robotic is a project to me over the years,
and I'll show you also some some historical pictures of our our first project to meet with the robot.
And if you look at the meta analysis, the reviews on this topic of many movies visual object to me.
Actually, these are the items that always pop up and that the beneficial parts of a minimum of Asia for objectively are less blood loss,
less complications, less pain and a faster recovery, actually, as we know also from for a coral rectal surgery.
And the same counts for many, many years of physiologic to me. And I think this is really a landmark paper by Jim.
Look at Age, who is in Pittsburgh and already in 2003, reported on 222 patients.
Really impressive. He is one of the pioneers of this technique.
I visited him in 2003 and I saw his technique and I thought that we could convert this technique into a robotic technique at that time.
And this is actually the major landmark paper showing a randomised controlled trial of open versus minimum age is of Jack.
To me, it's from the group, from Amsterdam, from Hugo Questar,
showing especially less bone marrow complications and also less pain after one year follow up,
meaning that the thoracotomy syndrome, which is causing pain, is still up to one year,
resulting in a better quality of life after minimally invasive these objects.
But still, this technique and this is a positive publication 2012 look at its 2003.
This technique is not widely adopted.
In 2007 and 2014, we did a survey amongst surgeons of the international societies for his office use through the Ujo and I as the EA.
And here you see the distribution amongst the continents. About 250 222 surgeons were questions about a preference of surgical approach.
And you see, in 2007, the minimally invasive technique is about 10 percent of all cases, and that increased to 40 percent in 2014.
But the open technique still still nowadays, I think, is the standard of care.
And maybe this this percentage has now increased that we are planning to do another survey next year.
And but I think it will not be much higher than 50 percent,
so what is the reason that this technique or those shown beneficial in is still not very widely adopted?
I think it is overdue. Your surgery is really one of the most complex type of surgery involving the chest involving
the moving organs in the chest with a very narrow band of of the section that you have.
At the same time, you have to do a radical resection and with the minimum invasive surgery, have the two dimensional view.
You had disturbed our hand coordination loss of dexterity because of the rigid instruments,
and you are dependent on the assistance for the camera of you.
And that is where I think robotic surgery comes in,
showing you a three dimensional view 10 times and large should really looking very closely to the tissues.
Looking through the plains very nicely, the natural eye and access is restored so you don't stand in an awkward position for your back,
for example, high degrees of freedom because of the risks of the instruments.
Actually, all the all the, uh, everything you can do was a pulse and more can be done with this instrument instrument.
And I think this is the reason that for complex procedures such as is object to me, this is an excellent tool.
We were very lucky to have one of the first robotic systems worldwide in 2002.
We had the first standard system of DA Vinci in our hospital, which is a university hospital in Utrecht.
And this is the device we had on the lab. So we had actually two systems.
One was in the clinic. One was in the lab so we could develop new procedures.
And we really at that time had no idea what procedures could be done robotically.
So we started with easy procedures such as cholecystectomy and just looking for
the optimal port position at that time because this is the standard system we had.
You see, it is very bulky if you know the robots at this stage, the development after 20 years is much, much, much more elegant.
But the basic principles of this system were already there.
But you had to be very cautious in your positioning to be able not to get collision.
The consul was here where the surgeon is operating, and that has changed as well.
But the principles are still there and we developed this poor positioning for the thorax,
meaning that you have the camera in the sixth intercostal space and to the robotic arms
in the fourth and in the the cost of space and two to assisting ports at that time.
The patient is in prone position,
semi prone position to keep the lung out of the operative field so that you can approach the oesophagus from this side of the rights to direction,
and the robot was typically put in the dorsal cranial position.
And this is actually still the position we use with the sort essi robots.
And this way you have an optimal vision and you have an approach from the diaphragm
upper to the thoracic in that this really works very well with X iRobot's.
This position is also automatically put into place by the the robotic arms,
but this took us some time to get a four lap tube to find out which was the best position.
And then I will show you some papers we produced over the years,
starting with our early experience in 2003 to 2005 and looking to the description of the technique.
And it was published in 2006, and actually that was the proof of concept of this technique.
Then the the follow up paper was in British Journal of Surgery 47 patient describes showing
also the quality of this procedure with a short term safety and some early modifications.
And then between 2007 and 2011, we showed that also in a record of 100 patients, hundred and eight patients,
the oncological outcome was at least comparable to what we know from open surgery.
This is the survival curve in those patients, and we operated on there was a 300 patients in surgical oncology.
And you see that the majority of our cases is advanced.
Cancer is T three T for tumours of about 77 percent, and the majority also has a node positive disease at presentation.
Nowadays, we usually give neoadjuvant therapy, but in this series, because it was included with our early experience, it was about 70 percent that.
You achieve in therapy from 2006 on as your standard treatment before we did surgery only and with the median follow up of fifty seven months,
the survival is five year survival is about 50 percent. So that is at least as good as we found in an open surgery.
Then one of the very important things in the programme that we developed from 2003 on was the introduction of API.
EPA is a physician assistant. We have that system in the Netherlands introduced it.
So around that time, which is actually a nurse who is very educated in the certain area and we were very lucky to have Sylvia from the horses.
She was a biologist at that time and also trained as a script nurse, and we trained her, especially for robotic surgery.
And the reason for that was that we we had a resident at a stable situation before,
and every time the resident went for his next steps, he went away and the programme went down and we had to train the rest.
It was the chief resident and he was there was most of the time, a good surgeon.
But the programme was not flying because you had you had this dip all the time when a new resident come in and this this changed
really this this point with continuity of troubleshooting of a specialised nurse that knows everything about the instruments,
the board positioning and the assistance. So from that on, we really could, could improve and could build up.
And I think another important step for us was the standard system,
which you had until 2009 was changed by the by the next generation to see system, and there was an important step as well.
And another important step for our programme was the and the staff member also dedicated to robotic is obviously what surgery was usually Huda,
who is now with us since 2011.
And I think when you have a PR physician assistant and you build up your team with another staff member fully dedicated to this procedure,
that is really possible to to make the next steps. And we looked into our learning curve at that time.
The learning curve of myself and we compare that to the learning curve of the new colleague Yellow.
And so we looked into the area of 2003 to 2016, and the initial case was of three hundred and twelve patients and the proctor,
the two hundred and thirty two cases and the north is 80 cases.
And we looked into that. Um, the data with the Q some methods, which means that you calculate for each item,
you calculate the mean of the whole group and you can have that as a as a reference.
And for each sample that you measure, you will measure the difference of the sound of the of that sample with the mean that you
just calculated and then you have three options even and the sample is above average,
which means that you are not not improving.
Actually, it's at the level then the same as the average.
Then you are a horizontal or you go below the average and then you are actually improving with your with your learning curve.
And we looked into two items the operative time and we are looking to blood loss.
And this is my curve starting in 2003. And you see that in 2008,
the learning curve is is actually completed because you have a flattening of this line and you see that even after 130 cases,
the line goes down, meaning that I'm improving actually all the time compared to the average, which was set at zero.
Then you see, in 2013, we were expanding our experience with more difficult cases.
So we're adding in, for example, T for B cases that we're down staged.
And then you see the the line comes up again for operative time.
But this is a very good measure. Looking at your, uh, you are experiencing a learning curve.
And then the the novice surgeon, he was introduced by a structured training programme,
meaning that he was first doing the table surgery, looking at about 20 cases.
Learning actually all the steps of the procedure. Then he was introduced into the console, with the console surgeon beside him for about 15 cases,
and after that, he was on his own, independently doing the procedures.
After about 15 cases, you see, that was happening within one year in 2012.
And then you see that only after about twenty two cases, including the proctoring phase,
he has completed his learning curve and the line was flattening off and even going under the mean.
And we also looked at all the oncological parameters during his training and all the
oncological like lymph node dissection number and also like radical was just crazy.
They were all at the level of the of the Proctor's surgeons.
So without compromising the the quality of surgery, you can introduce this technique.
And if you and then sum up what we did for this trainee, you see that the doctor completed his learning curve in seventy procedures.
It was five years was the pioneering series and with a structured programme, you can reduce this time by twenty four procedures within one year.
So that is a way we would like to continue for this, for training this and this technique.
So the conclusion from our experience in this stage 2003 to 2012 was that as feasible as technically safe and logically
safe and that you that we completed in this time the learning curve and also for the for the training programme.
So at that time, it was 2012. We and we decided that we could do this technique.
We could analyse the technique in a randomised controlled trial. There were no other centres worldwide that passed the learning curve at that point.
So we decided actually it would be nice to do multi-center trial where we couldn't do that and decided to do a single centre,
randomised controlled trial. Looking to this technique versus the open standard of transfer risk is over joke to me.
But was the protocol was published in trials in 2012 and these were the items we are looking at.
The study was running between 2012 and 2016.
I think the nice thing of a randomised controlled trial that you really can prospectively analyse all the data very, very precisely.
So to all the postoperative complications every week were discussed in a panel and
this court's been scorched prospectively quality of life oncological outcomes.
And we also looked even at cost because we know cost is with robotic surgery.
Always an item. This is the this trial was this year published in the Annals of Surgery,
and I will show you the results of the trial that we in total randomised one hundred and twelve patients looking into these two groups,
and we ended up with fifty five versus fifty four. And this is the baseline characteristics just to show you type of surgery.
It's the type of patients is typically male patients.
The majority of 65 64 of age, there were no significant differences in all the baseline characteristics.
The majority is out of the question normal about seventy eight seventy six percent.
And a majority is also in the lower part of the oesophagus, the lower third of the oesophagus.
As you can see here, about 80 percent received new HIV treatment.
Are the baseline characteristics concerning comorbidity and medical history,
you see that the majority had a comorbidity 75 to 80 percent has comorbidity and
the majority of that is cardiac and vascular and also pulmonary comorbidity.
Then to the to the results of this study, you see, the operative term is longer in the Romney procedure,
which is a field of 49 for just two hundred ninety six.
And you see that in actually all the robotic literature probably has to do also was a changing of
the instruments and the the more precise of the surgery that you are performing with the robot.
Blood loss was significantly less in the robotic group of 400 versus 500, the 68, and we had hardly any conversions.
The main outcome the primary outcome of the study was overall complications.
And you see this is significantly less in the robotic group of 59, which is 80 percent.
This includes all the complications. If you look more closely into the most common.
This is the pneumonia and pulmonary complications were significantly less in a robotic group 32 versus 58 percent.
If you look to cardiac complications and this is also, I think, very interesting,
it's mainly and for fibrillation, there is 22 percent versus 47 percent.
So there's also significant reduction in cardiac complications by M. Invasive surgery.
You're, of course, operating over the heart of the pericardium, which cause maybe the atrial fibrillation in.
So you can the 50 percent reduce this complication by many more invasive surgery?
Than to wound infections. There was a trend also to less wound infections in the water group.
This was not significant.
And especially in the terrific part, you see there is no one defection after the invasive surgery versus nine percent in the open group.
Then to the functional recovery, I think this is also very interestingly defined not only the day of discharge but also the functional recovery,
meaning that the patient is able to walk and to eat independently without any drains.
And this was also within two weeks in 70 percent of the cases, with robotic fresh 50 percent in the group,
significantly different functional recovery and the course of the procedure were calculated and they were not significantly different.
This includes not only the machine, but also the instruments, but also the cost for the hospital stay and the management of complications.
And because you have a higher complication, rates cost equal out, then quality of life.
We looked into two time periods at discharge and after six weeks following surgery and as an older man's physical functioning.
Also, health related quality of life was significantly better in the M.E of age group at all time points than postoperative pain.
We had exactly the same pain regimen in both groups with epidural catheter and the PCI and PCI in in all cases.
But but still you see that that old time points.
The minimum invasive surgery group has less pain than the open surgery group that continues until two weeks after the surgery.
Then the oncological outcome, we looked at all the parameters and we didn't see any difference between the oncological outcome.
So that's actually what you would like to see no difference in.
Well, look, go back, no difference in our zero rejection rate, which was about ninety three ninety 96 percent.
And also the number of lymph nodes, which was twenty seven and twenty five percent in both groups.
So no compromise in oncological outcome. This also translates into survival, with a median follow up of thirty eight months.
You see that the survival curves are parallel and about 50 percent five year survival in both groups.
So conclusion of this trial is that the minimum wage of robotics was open is improving postoperative outcome, a lower percentage of complications,
lower cardiopulmonary complications and less pain, better quality of life,
better short term functional recovery cost equal and oncological comparable.
And what our future developments are will hopefully have time to show you a short movie of our technique of T for B,
that means the tumour is invading the adjacent organs in most of the time in the talks after chemo radiotherapy you can downstage,
you can with this technique, even in upper mediastinal tumours, you can dissect it because you see it so well and you have all the dexterity.
We do a hand-sewn introduction on this. The most is and we have introduced with the new robots the four arm technique because
you have your are dependent on the intercostal space with your troca positioning.
It's not so easy to have four arms, but with the new robotic systems with the very elegant and small arms, you can do that.
And also the abdominal phase was now introduced robotically because of the multi quadrant capacity of the new robotic systems.
And finally, we are training our other centres and also training fellows and residents in this technique.
This was a major next step. I think this is the robotic DaVinci Ixion with a completely new concept of the arms of the robotic arms.
Very elegant and with a lot of dexterity and really designed for multi quadrant surgery.
That means that we can now use four arms techniques,
and this makes the surgeon really independent of the assistance, the table assistant is not so important anymore.
You don't need any clipping anymore. You don't need any cutting.
The only thing the table situation now does, and I think a script nurse can do that is the suction.
So you're not dependent on the second surgeon. You can really operate and you can expose your own field without without an assistance.
This is the poor positioning.
Be designed for the four arm technique and again, little bit different, but also the same principle as we had with the three arm technique.
But you look into a curve the positioning of your toe course in order not to have any collision.
And this is the the setup we have in Utrecht.
We have a dual control system.
The advantage is that you have the surgeon and you can have an experienced surgeon if you have a difficult case to help each other,
for example, but it's especially used for training purposes.
So you have the ability to take the arms for a short period of time or two to point with.
You have a pointer 3D printer where you can guide the trainee through the 3D operation.
It's really an excellent way of of training surgeons.
This is the abdominal positioning we use actually a straight line for the abdominal ports.
And we use liver retractor, so you don't need to have.
You can also start using the fourth arm as a liver objective. It's much better to have the fourth arm if as an active surgical arm.
And this is the the abdominal poor positioning and the phenomenal setup of the of the patient.
Then I'd like to show you a few films, short movies.
This is the abdominal part and you can see we all have the gas, the conduct and you see this is very nice.
You have a wristed stapler. So this is a robotic wrist.
It's very, very exactly control the the angle of your stapling.
And this was the guest economy that just shows you this is the Linfen activity we're running over the station age.
This is the common hepatic artery towards the portal vein.
So a very short clip just to show you how you can can do this abdominal abdominal phase.
And this is the the setup we have in our old car or in Utrecht.
We start here, you look towards the vertebral column of the patient.
So you really have to adapt to this anatomy.
Also, you see older structures very much enlarged and you really have to to get used to that and take the advantage of that.
This is the wristed instrument showing the Humalog clips of the crossing, the zygier's vein.
We're looking down to the upper mediastinum and the dressing in that you can see you can see because you see the plane so well,
you can now remove over the trachea sparing.
This is the recurrent nerve at the left side pointing upwards.
So you can do a very extensive para tracheal lymph connectome at both sides.
Shapiro cable vein running over disappear. OK, vein at the right side at the left side is a joke.
Here you see the vagus nerve, the trachea at the upper Torres Inlet, and you see that there is a lot of dexterity.
This is a vessel seated bipolar device that can congratulate the structures.
This is the vagus nerve and the right side where we're running over.
We cut the vagus nerve just below the right main bronchus.
And here at the level of the diaphragm is the thoracic duct,
which is encircled and is taken with the specimen and is with again the restored clipping device is.
Is there to take off the clipping you, you see the thoracic duct. Now we have lifted at the level of the diaphragm, you have lifted the oesophagus.
As you can see, you can take the vessel sealer as a as a retraction device and we move over to pericardium,
which is down below to the coronial sip coronial notes.
This is the right main bone because you see the cartilage of the Rypien bronchus and you
can see how you can move over the right and left main bronchus taking all the tissue out.
This is the gash. The comedy was created in the abdomen and we take it up into.
The oesophagus is dissected and we measure the level of the anastomosis we use.
ICG and the ICG is used as a measure of the vasculature of the conduit in case we have a vascular top.
We will. We will staple it off.
This is the similar technique we use nowadays, which is a handsome technique with a running suture, posterior and anteriorly.
And this is a bracketed suture. So you have like a v lock.
This is a strata fixed suture and we use V and the anaesthetic technique with amount of plastic surrounding the anastomosis.
I hope you can see the rest of the instruments really help you. This is we were in the upper and upper mediastinum.
Now we are down below the diaphragm doing a cruel plastic.
And this is the end of the thoracic procedure where you have everything done.
Then I'd like to show you an experiment we do with ICG.
This is a fluorescent substance that was injected preoperatively the day before surrounding a tumour, and we are looking now at the Seelig trunk.
And you with a light images,
it's very difficult to distinguish the lymph nodes and to to distinguish that from the pancreatic tissue in a fatty tissue.
But with the as you can see here with the ICG, you see a lymph node appearing there that was actually, uh, just at the border of the pancreas.
Not so easy to distinguish, actually impossible to distinguish without ICG.
And you can take it this way. You can really identify lymph nodes that you couldn't see before, and we use it now in early tumours.
We have a group of patients that were treated with ESD, and they had bad histological logical characteristics, and they need a lymph node next to me.
And we use this now as an experiment. Then to conclude, I would like to show you our programme of proctoring and training this technique.
This is the group of Bruno also is as part of this issue, very nice group of European, um, minimally invasive oesophageal surgeons.
We had several meetings and we have a meeting this year again in Munich next month.
We come together and discuss various topics on this technique and really aiming for the dissemination of this technique.
And one of the things we did was the finding in Adelphi consensus meeting the
the way you could build up a structured training programme for this technique.
And we came up with several items and a summary of that is the what is it?
What is the what is mandatory for a team to start up this technique? You should have these have two surgeries dedicated to this technique.
I think otherwise it's you should really have support of your your team,
preferably also dedicated anaesthetist and scrub nurses because you don't want to wait all the time for the setting up of the system.
You want to have a smooth programme running and and then you have the dedication is very key for this.
Then the sufficient caseload, I think in the UK, there's no discussion about it, but there are countries where there are hospitals doing less than 20,
and if you have less than 20, you take too much time to get through your learning curve.
So we decided at least 20 cases a year. You need to to start this programme,
and this is very important for your board of directors that you have a guaranteed access to the system because if you do some cases and then months,
you don't do anything, then you really have to start up again. There is a simulation programme that you can do in between, but it's, I think,
very important to have access weekly access to this, to this reporting machine.
Then what about the programme we have run running that been running now for the past years?
It started with the case observation team comes to the expert centre and to observe, preferably with the whole team,
the the procedure and the one or two times is, I think, an excellent way to start a programme.
Then we advise to do go for a basic course, basic robotic course.
Also, the basic training course, as we are running in Utrecht, was endorsed by Esso and just analysing the technique was lectures,
was hands on experience and then after that to do a specialised cadaver training where you have
the access and the hands on with the proctor during the day to go through the whole procedure.
After that, the boxing programme is started on site and the proctor is coming to the through
the unit of the trainee and is getting through to the cases step by step,
preferably during the period of of some weeks.
This is the training programme we are running since 2009 in the Netherlands.
It's in the Utrecht.
It's it's a it's a yearly programme of two days and we trained all the surgery in the Netherlands and now training with the endorsed,
of course, also surgeons worldwide in this technique.
The next course is March five to six, 2020.
This is how it looks like we have a skills lab where we have also a cadaver facility,
where you have small groups with each of them, a proctor will guide you through the system and through the technique.
And we have now several we have now several of those robotic systems as well available.
And this is an artificial model where you can train the suturing robotically,
and here you can see also some some other models that you can use for your training.
And I think especially also the now the simulation programme that is available
on the da Vinci robot is excellent for you for training your your skills.
What are we doing now? We have had more than 40 teams coming over and we have three teams in the Netherlands trained.
There are also some teams that we trained that are now put Proctor for intuitive and are training on a teams in the Netherlands.
I think now in total, there are about five teams, two teams on the way and three three four teams in the Netherlands and the UK.
And we have very recently and a second team that now finished and two are on the way.
And in Germany to finish and one is underway and this is the group of of countries and surgeries that fish this over the past two years.
Then this is also a very exciting and crisis here.
And he is the first. He is the fellow.
We designed the fellowship programme because trainee surgeons, I think, is very important.
But training fellows even may be more important to train them and have a year of experience and really
hopefully have them ready to set up and to help setting up a programme at their home institute.
And this was the reason for this European myI Fellowship and this is fresh use on the website.
And he has already done his basic course so you can see on the left side and here you see, he is really part of the group.
He's really, really happy to have him. Yeah, I'm really grateful that we were able to have to have such an intelligent young surgeon with us.
You see, don't love visiting us a few weeks ago and you see the whole group you're dressed.
So another thing is the air,
which is the Upper GI International Robotics Association found it's very recently also dedicated to the dissemination of this technique.
And this is another fellow.
This is Peter from the sloughs, and he's the first author of our robot trial. And this is Peter Grimier.
We trained him now three years ago in and Brahmi, and he was already done within two years, more than 100 cases.
I think that's really a very successful programme.
He's now official, Proctor also for four robotic origami procedures and you have he has Peter from the stage as his fellow.
So we're very proud of that. I think we can I can finally show you this my last video.
This is an advanced case of T four B cancer.
And oh, and this this shows you actually in the ultimate form of how you can use robotic techniques.
You see a lot of that positive knowledge in the upper mediastinum. This patient was treated with chemo radiotherapy and had a ibas.
So, um, showing that there was a growth in the trachea restage after the adjuvant chemo radiotherapy and then was downsized,
but still had positive pet positive notes on this on this pet scan.
So we we did a rejection. And this is something I would, I think, really showing you the benefits of this technique.
This is our old or I always draw the poor positioning.
I think every patient has a different than enemy and it's always important to really draw exactly the ports.
On the basis of some landmarks. This is the S-i system that was we used before.
And you see the way you can manipulate the instruments in a console.
Now we're looking again at the level of the pericardium.
This is at the level of the diaphragm again, you see. We do the cutting of the crossing, a zygier's arch.
This is done with the hemlock. You can see how very nicely you can restore the instruments.
And here again, you can see how we can. We can move over to, as, I guess, fame.
And then you get to the after getting all the lymphatic or the lymphatic tissue that that can contain lymphatic metastases.
Here we are in the sub Coronil area. And there was a lot of reaction because of the chemo radiotherapy.
This patient did a lot of oedema, but.
Because you see, it's 10 times in large, you can very precisely move along all the area, all the in the vital organs you see here,
the left main bunkers, you see the whitish coring of the tissue, which is typically after chemo radiotherapy.
It's a very strong reaction you have of the tissue, but because you see it so well, you can very precisely move over the member in this part.
And this is the structures we identified as the Mesereau's all figures.
You see you open up to the fascia and then you come into a plane with the lymphatic and also the and the are the direct auto itself to your branches.
This is the upper mediastinum and this is the tumour.
You can still see at the very much connected to the memories part of the trachea because you see it so well,
you can exactly with your hook up very, very localised energy transfer of the DETERMINA.
You can dissect it of the member in this part of the trachea without damaging the.
And you see that in the upper mediastinum, there were still some positive notes, very strikingly positive notes.
That were dissected, this is the the left side of the turkey and the turkey is pushed downwards with the suction.
And here you see the superior cable vein along the superior cable vein and the turkey
also and large positive notes that can be dissected along the right recurrent nerve.
And I think what is really striking that you hardly see any blood and that's the reason you because you're following all the planes,
um, there's virtually very little blood loss in this is difficult procedure.
There is this is the area of the subclavian vein and artery where the recurrence right recurrent nerve is running.
So over the right trigger and nerve and enlarged lymph nodes are dissected as well.
And this is the image of the waterways, the intercoastal arteries.
This is the the image you get when you have a radical than a radical limb for the next to me with unblock,
this section of the oesophagus and the lymphatic over the period kadhim over the aorta.
The left pleura there. And the is the ship Gravano, the ship Chrono, our notes are on block dissected.
You see the the pointed right and this is the pulmonary vein and the right and the left main bronchus.
OK. There was a thank you very much for your attention.