Derby Pancreaticobiliary & Robotic AWR Unit

𝗙𝗲𝗹𝗹𝗼𝘄𝘀𝗵𝗶𝗽 𝗔𝗱𝘃𝗲𝗿𝘁 Our Post CCT/Senior Complex Benign PB & Robotic Fellowship at @UHDBTrust is now open for applicants to start from Aug 2026. Gain experience in advanced laparoscopic and robotic benign PB surgery. In addition, fellows will develop skills in laparoscopic and robotic hernia surgery including complex abdominal wall hernias as well as training in ERCP. Advert below or DM for more details: nhsjobs.com/job/UK/Derbysh…

Robotic TAPP (rTAPP) Repair of Left Inguinal Hernia with Imbrication of Transversalis Fascia Why imbricate: 🔵Direct defect/large hernia risk factors for postoperative seroma 🔵In open hernia repair, direct defect often closed ➡️Helps create a flat posterior wall and expedite mesh placement 🔵However it is not a routine practice during MIS Robotic Imbrication of Transversalis fascia: 🔴Possible advantages include: ➡️Reduce seroma risk formation ➡️Reduce risk of recurrence (mesh migration) 🔴Avoid deep bite ➡️Cord structures can be easily caught in sutures

𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗧𝗿𝗮𝗻𝘀𝗮𝗯𝗱𝗼𝗺𝗶𝗻𝗮𝗹 𝗥𝗲𝘁𝗿𝗼𝗺𝘂𝘀𝗰𝘂𝗹𝗮𝗿 𝗨𝗺𝗯𝗶𝗹𝗶𝗰𝗮𝗹 𝗣𝗿𝗼𝘀𝘁𝗵𝗲𝘁𝗶𝗰 𝗥𝗲𝗽𝗮𝗶𝗿 (𝗿𝗧𝗔𝗥𝗨𝗣): 𝗕𝗼𝘁𝘁𝗼𝗺𝘀 𝗨𝗽 𝗔𝗽𝗽𝗿𝗼𝗮𝗰𝗵 Advantages of Approach: 🔴Overcomes limitations of lateral docking to achieve adequate cephalad dissection beyond defect 🔴Option to extend dissection into TAR plane ➡️Indicated in cases where approximation of defect becomes difficult 🔴Allows good mesh overlap 🔴rTAPP approach can be difficult ➡️Thin peritoneum laterally ➡️May not allow defect approximation in absence of posterior rectus sheath release for defect >4cm See our paper on outcomes during the learning curve and implementation of the @eurohernias guidelines for RAWS in the UK: frontierspartnerships.org/journals/journ…

𝗔𝗻𝘁𝗲𝗿𝗶𝗼𝗿 𝗚𝗮𝘀𝘁𝗿𝗼𝘀𝘁𝗼𝗺𝘆 𝗮𝗻𝗱 𝗥𝗲𝘁𝗿𝗶𝗲𝘃𝗮𝗹 𝗼𝗳 𝗜𝗺𝗽𝗮𝗰𝘁𝗲𝗱 𝗛𝗼𝘁 𝗔𝘅𝗶𝗼𝘀 𝗦𝘁𝗲𝗻𝘁 🔴Anterior gastrostomy just at level of palpable bulge and proximal to pylorus ➡️Correlated with Hot Axios position on CT 🔴3/0 PDS used as stay sutures to improve visibility ➡️Just anterior leaf of gastrostomy ➡️To falciform using slip knot 🔴Despite manoeuvres described difficult to visualise Hot Axios stent 🔴Ligaclips applied to mucosa where stent could be palpated 🔴Intraoperative XR screening used to orientate the stent in relation to ligaclips 🔴Hook diathermy used to divide stomach mucosa to the right of the ligaclips to identify the stent which proved to be unsuccesful 🔴Real time IOUS utilised ➡️Critical step ➡️Key in identifying location of Hot Axios stent 🔴Once identified the stent which buried beneath the mucosa was removed with careful traction 🔴Bleeding encountered upon stent retrieval ➡️Controlled with pressure, judicious use of diathermy and placement of Veriset 🔴Anterior gastrostomy sutured close in 2 layers with 3/0 PDS 🔴Postoperatively patient started on IV PPI and initiated on oral fluids and diet in stepwise manner #FOAMed #GITwitter #EUS #HPB #SoMe4Surgery #surgery

"Hot" Laproscopic Cholecystectomy 🔴Principles remain the same 🔴Know bailout options ➡️Subtotal 🔴Gallbladder decompression 🔴Identification of Rouviere's sulcus if present 🔴Endo pledget very useful in these cases 🔴Suction/irrigation ➡️blunt dissection 🔴Demonstrate CVS

Tips & Tricks for Minimally Invasive Adhesiolysis 🔴Controlled but purposeful traction and counter traction to divide adhesion ➡️See image below with arrows 🔴Blunt instruments i.e. Johann 🔴Useful for adhesions between bowel loops

Emergency Robotic Chole and CBD Exploration in a Pregnant Patient Presentation: 🔵23 year old 20/52 pregnant presents with obstructive jaundice ➡️Uterus at the level of umbilicus 🔵MRCP demonstrated GB and CBD stones ➡️A single 8mm stone impacted in the distal CBD ➡️CBD >8mm in diameter. 🔵Benign MDT decision that MIS chole and CBDE was the best approach to manage her condition 🔵Proceeded to Robotic Assisted Chole and CBDE Surgical Approach: 🔴4 robotic arms and 1 assistant port 🔴Careful open cut down just below umbilicus taking care to access the peritoneal cavity taking particular attention to avoid injury to the uterus 🔴Early positioning of patient in reverse trendelenburg with right side tilt to take pressure off IVC 🔴Cystic artery dissected and ligated 🔴Choledocotomy ➡️Clear bile indicative of obstructed CBD ➡️Open jaw technique ➡️Extension of choledochotomy over the captured stone in the basket pulled to the entry of the choledochotomy 🔴Choledochoscope through cystic duct and irrigated to flush out smaller stones via choledochotomy 🔴Wide cystic duct dissected 🔴Proximal extent of the duct suture ligated 🔴Cystic duct divided to release cystic duct stones 🔴Stones flushed through the cystic duct during transcystic choledochoscopy 🔴Cystic duct sutured closed with 2/0 Vicryl. Benefits of Robotic Platform: 🔴Low pressure pneumoperitoneum at 8mmHg feasible with precision wristed robotic instruments and magnified 3D enhanced vision 🔴Improved ergonomics for closure of choledochotomy @SAGES_Updates Guidelines for Laparoscopy during Pregnancy: sages.org/publications/g…

Delighted to see @altaf_awan12 host and run the TR200 Hernia Course at the @IntuitiveSurg HQ in Winnersh, Reading. We welcomed Sebastian Schaaf from Bundeswehr Central Hospital in Koblenz, Germany and Moritz Sparn from HOCh Health Ostschweiz in Startseite, Switzerland alongside their residents.

Delighted to have hit 10K followers on X/Twitter. Thanks to all our followers for supporting our content. We have enjoyed sharing our work and communicating with a worldwide audience. Let us know what you would like to see from our page in the future!

Robotic Reduction of Contents in Incisional Hernia 🔴Bridging scar tissue in honeycomb defects can be divided selectively to release incarcerated small bowel or omentum 🔴Dividing bridging scar tissue increases space to allow safe manipulation and reduction of contents 🔴The scar tissue relation to skin is variable so experience is required during division to prevent skin button hole(s) 🔴Robotic manipulation of bowel/omentum requires judicious use to prevent accidental trauma 🔴Holding onto mesentery rather than bowel during reduction of contents or using curved (articulated) part of the instrument would be preferable

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

Delighted to host the inaugural @ALRSGBandI Laparoscopic CBD Exploration course at the @KARLSTORZUK training centre in Slough. An excellent day that included video talks on difficult cholecystectomy and approach to LCBDE, followed by practical skills of transcystic and transductal CBD exploration. Many thanks to all our faculty for supporting the delegates and for @KARLSTORZUK for hosting us. We look forward to the 2nd iteration next year!

High BMI Robotic Chole (Previous Abandoned Lap Chole) Patient Presentation: 🔵BMI 65 🔵Biliary colic with 2 attacks of mild pancreatitis 🔵Abandoned lap chole ➡️Large liver precluding view ➡️Torque on abdominal wall Surgical Approach: 🔴Pre operative optimisation key ➡️VLCD for 2 weeks preoperatively ➡️Weight loss helps make abdominal wall pliable ➡️RCTs have shown its effect on reduction in liver volume 🔴Right lobe of liver may still be quite large and bulky as shown in video ➡️Liver may not retract due to its size and limitation posed by subcostal margin, so view will be less than optimal 🔴Robotic ports placement x4 ➡️15-20 cm from subcostal margin 🔴Assistant port (12mm) ➡️Triangulate between 1st and 2nd(camera) robotic ports ➡️Downward retraction of duodenum/omentum which helps improve hepatocystic triangle view/dissection and overcome limitations posed by incomplete liver retraction ➡️Consider long length Johann forceps. 🔴4th arm would provide stable liver retraction ➡️Swab under Cadiere forceps would help protect soft, bulky liver ➡️Keep in view at all times 🔴IOC/ICG/robotic ultrasound good adjuncts 🔴Due to longer length of robotic instruments, a lower port placement (similar to cholecystectomy in cirrhotic liver patients) and 30 degree scope flip helps facilitate CVS dissection where liver retraction is not optimal

Camera Flip (Image Inversion) during Robotic Ventral Hernia Repair Image Inversion Process 🔴Involves a three-step process: ➡️Unlocking the display ➡️Reassigning robotic arms via the “manual command” button ➡️Flipping the 30° endoscope lens in the opposite direction. 🔴This reorients the surgical field so that movements in the upper space (“ceiling”) of the display are transformed into movements in the lower field (“floor”) Benefits 🔴Improved Ergonomics ➡️Reorients the surgical field for intuitive forehand suturing ➡️Reduces physical strain during ventral hernia defect closure 🔴Enhanced Precision ➡️Facilitates accurate suturing ➡️Assists with tension-free fascial closure Technical Requirement 🔴Requires expertise with the robotic platform and proper execution of the image inversion process

@droktaybulur @Innov_Medicine @SAGES_Updates @BrownJHM @EAHPBA @IHPBA @MarcBesselink @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Thanks for your comment. Single staged debridement of WON whilst allowing drainage of RIF collection. We reserve EUS for dominantly liquid collections that are anatomically retrogastric. See our collaboration with @BehindTheKnife for more details: behindtheknife.org/video-playlist…

@DerbyPBunit @Innov_Medicine @SAGES_Updates @BrownJHM @EAHPBA @IHPBA @MarcBesselink @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Dear dr why you dıdnt make eus guıded necrosectomy.?ı thınk there is a way from stomach .

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 @JournalofGISurg: sciencedirect.com/science/articl… #Surgery #HPB #Pancreatitis

𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗥𝗲𝗰𝘂𝗿𝗿𝗲𝗻𝘁 𝗥𝗶𝗴𝗵𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 𝘄𝗶𝘁𝗵 𝗠𝗲𝘀𝗵 𝗘𝘅𝗰𝗶𝘀𝗶𝗼𝗻 𝗮𝗻𝗱 𝗜𝗖𝗚 🔴Previous open preperitoneal mesh repair for symptomatic right inguinal hernia 🔴Presents with recurrent right inguinal hernia ➡️Likely technical failure as a result of inadequate dissection rather than mesh shrinkage 🔴Decision to proceed to robotic hernia repair with excision of mesh ➡️Robotic platform facilitates precision dissection 🔴Initial dissection above and below the mesh helped identification of anatomical landmarks 🔴Judicious excision of mesh ➡️Tiny disc of mesh left at deep ring where separation attempt appeared unsafe 🔴ICG useful adjunct to confirm the integrity of vas and gonadal vessels ➡️Excellent tool for trainees to appreciate inguinal anatomy

We are pleased to announce that we have joined the @surgeonapp1 community! We look forward to sharing our work and engaging with our colleagues worldwide on this excellent platform.

Role of T-tube in Lap EGS: Redo Laparoscopic Repair of Perforated Duodenal Ulcer Patient History: 🔵Day 5 post lap repair of perforated DU ➡️2 x previous repairs ➡️Return to theatre 24 hours post index procedure due to high volume bile from drains 🔵Septic unwell patient 🔵4 quadrant bile peritonitis on CT Surgical Approach: 🔴Copious peritoneal washout 🔴Identify area in question 🔴Remove loose sutures 🔴Size 8 T-tube ➡️Controlled drainage ➡️Facilitates healing ➡️May help prevent leak from suture site ➡️Bring it out to skin via shortest route i.e. along falciform ligament in perf du ➡️Intraperitoneal drains at site of perf mandatory requirement ➡️As latex free, suggest to leave for 12 weeks for T-tube tract to mature ➡️Tubogram prior to removal Postoperative Outcome: 🟣Post-op tubogram showed no leak at site of repair 🟣Interval CT showed small volume collection not amenable to intervention 🟣Prolonged postoperative stay due to requirement for IV antibiotics as per MCS 🟣Discharge D21 post redo repair ➡️6 weeks of OPAT completed ➡️Interval CT showed resolution of collections ➡️Tubogram at 12 weeks showed no leak ➡️T-tube removed after tubogram ➡️No further readmissions to hospital

@BehindTheKnife Congratulations on an excellent achievement 👏

987 episodes as of today! Earbuds to the OR ➡️ journals.lww.com/annalsofsurger…