BTK Swan Song-20250506_200333-Meeting Recording

Hello behind the knife. Listeners, we are back with you. This is our last. Episode o Tonight we're gonna be discussing our last journal club and colon and rectal surgery on hand assist laparoscopic surgery with the Leahy colorectal surgery team. We opted to not do a special guest for our final episode.

It's gonna be the core three of us breaking down these articles for you guys highlighting the use of hows providing some tips and tricks and when it can come in hand.

Go, John. That was good job. All right. So, today we're gonna tackle some articles that are really central to the discussion on the use of hand cyst and in colorectal surgery. So there's lots of ways to approach a case. We feel that hand cyst

laparoscopy is a, a very, very important tier technique.

It's near and dear to our hearts here at Lahey. And so we wanted to end our, our time here with Behind the Knife to really go into. The literature on its use and its benefits. And so, one of the articles is by non our own Peter West Marcello. Mm-hmm. Randomized prospective trial comparing ha, Hals and laparoscopic surgery.

And then the other article we're gonna go into is laparoscopic colorectal surgery for obese patients and decreased conversions with the hand assist technique. So welcome to the team, Dr. Peter West Marcello, Dr. Tess, Hannah Ette. Hey guys, it's, it is really great to be back. It's springtime, the National Meetings company.

We, we just had our New England colorectal meeting, which was awesome. But this has always been sort of a special place for us to sort of, talk and engage and really enjoyed. I. Working with this team. Phenomenal work. I gotta say I've had the easiest job 'cause I just come in and make the comments here and

there and Tess and John deserve the credit for doing the, the oman's part of the work so great to my team here for their help, Tess.

Yeah, I mean, I can't believe it's already been four years that we've been doing this. Gonna miss it for sure. But I'm really excited to hear some new content by some of the new teams. I remember when we did our, like, audition in my office. Yeah, yeah. I was still a fellow and we huddled in your office and yeah.

You know, made a recording and yeah. The, the rest is history. The rest is history. All right, so we talked about how, how has a lot of re relevance to the lay team. So, it does all start here for us, at least for me and Peter with or, sorry, excuse me, me and Tess, with, with Peter and some of your background on how, and so can you prime the audience a little bit about how and your experience with how you came to it.

Yeah, and I think it, it, you really have to go back to the mid nineties

when laparoscopic colectomy was just starting and really realize, again, as we've talked in other, other episodes in different areas, that the challenges of doing a laparoscopic colectomy from open, it was phenomenal. Just doing a gallbladder was hard.

You had general surgeons who were doing gallbladders but don't do many colectomies, and you had colorectal surgeons who were doing. Plenty of colectomies, but didn't do simple laparoscopy. So when the co surgeons tried to do this complex procedure, they couldn't really get a handle on it. And so we started with Dr.

Milsom. I I started doing. Laparoscopic colon courses teaching the general surgeons and colorectal surgeons across the country. And the adoption was poor. Like we would bring 10 surgeons to a lab, maybe two could pick it up. And what we found was that for the colorectal surgeons, they didn't have the skill sets.

And for the general surgeons, they didn't have a clear understanding of the anatomy. And then. Putting a hand in allowed the cohort surgeons to

have better laproscopic skills 'cause of proprioception. And for the general surgeons, it allowed them to sort of feel more comfortable with the anatomy, even though they had laproscopic skills.

And so when we started doing hand assisted courses to teach and train, we had about 70 to 75% adoption with this technique. And so the hard part was while I thought that it was a good procedure and we did studies. We couldn't really convince the zealots those that were doing laparoscopy, that it was really a minimal invasive operation.

So we really needed a trial to show that there were some unique advantages for the hand in terms of time and conversion, but, but it wasn't really gonna change much of the outcomes. And so, I'll talk after we talk about the study, I'll tell you a little bit about how we went about it. Nice.

All right. Well that was a great introduction, Tess. Do you wanna kick us off? Yeah, so I'll be and if you're watching along on YouTube, I pulled this off the interweb you can see a

picture of none other than Dr. Marcelo doing. Hand assist laparoscopy right there on your screen.

So I'm gonna be heading off the first paper. This was a multicenter study with many leaders in the field when it comes to both laparoscopy and colon and rectal surgery. The purpose of the study was to compare the short-term outcomes after. Hand assist laparoscopy versus straight laparoscopy, and the authors hypothesized that operative time would be shorter for the hand assist group or the house group while maintaining similar clinical perioperative outcomes.

The study was o done at multiple centers. There were five centers that participated with a total of 11 surgeons. It was a prospective randomized trial where patients who were planning to undergo elective laparoscopy they focused on two procedures, either a sigmoid, a left colectomy, and then a total abdominal colectomy.

The surgeons and sites were

selected because. All of these surgeons and centers were experienced in both hand assist as well as straight laparoscopy. I, you know, one of the things I thought was nicely done, the conflict of interest was clearly stated in the paper. This is not industry led. The investigators initiated this trial, but was industry supported.

The procedures. Were chosen the total abdominal and sigmoid colectomy because they were felt to be both well suited for both approaches. Whereas a right colectomy sometimes your hand gets in the way because of where the camera would normally be. So again, they focused on the procedures that would be well suited for both approaches.

Patients who had other procedures in the same operation were excluded that may impact timing. Emergency procedures were excluded and patients who were not suitable for a laparoscopic approach, if they had dense adhesions or significant cardiopulmonary disease patients were then randomized in. Into either hand assist or laparoscopy, straight lap.

And then patient data,

inpatient and post-op data was collected. The straight laparoscopy group performed usually had four to five ports and an extraction site. Could be anywhere in the lower midline fan and steel or the left lower quadrant and could have an intra or extra caboral anastomosis.

They define hand assist laparoscopy, typically a seven to eight centimeter lower midline or fan and steel incision to accommodate a hand device, and then usually a additional three to four TRO cars. Conversion was defined as any modification to any extraction site, and thus the straight lap group could convert to hand assist or to open post-op care was standardized.

And the diet was standardized across institutions. The pain control was standardized with PCA. And Toradol at the surgeon's discretion. They did track postoperative narcotic use as well as patient pain scores. Patients were not blinded to the technique that was used.

The study tracked the operative time for left colectomy and skin to skin.

And this was done skin to skin for the total abdominal colectomy. They measured the operative time in two ways. They did do skin to skin, but then also. Looked at the skin to the mobilization or devascularization phase which I thought was really smart because obviously after you do a total abdominal colectomy, there's a lot of variability in terms of what steps might come next, whether they had an end ileostomy, obviously as quicker than a proctectomy with an ileoanal pouch.

So again, they controlled for that in terms of a. Operative time. The study was powered to detect a 30 minute difference in or time between the groups. There were 47 hand assist patients, 48 lap patients with good and equal distribution between the left colectomies and the total colectomies. They were equal in regards to sex, age, BMI.

History of prior surgeries. Diagnosis and why the procedure was being performed. Another thing they

controlled and tracked was resident participation in the case as well. They found no significant differences in the procedure performed, intraop complications or resident participation. However, the mean operative time was significantly less in the HAL group for both sigmoid colectomy.

175 minutes versus 208 minutes with a mean difference of 33 minutes. And also found a decreased operative time in the total abdominal colectomy group with 127 minutes versus 184. So that's a mean difference of 57 minutes. So that's a good chunk of change there. There was a statistical difference in the intracorporeal anastomosis happening more commonly in straight lap.

61% as compared to 14. But this was not statistically significant. There was no difference in return of bowel function, diet, toler tolerance, length of state pain scores or narcotic use. There was one conversion in the hand assist group and six in the straight. Lap group. Most of these conversions in the straight lap group were to hand

assist and again, not statistically significant.

Overall, the authors concluded that hand assist laparoscopy had significantly shorter operative times when maintaining, while maintaining similar outcomes. Despite controlling for a lot of factors which I thought they did quite well, I found a few things interesting in this paper. One of the differences in technique for hand assist, which was kind of alluded to a little bit in the paper was, you know, how the hand port was used.

There was difference between different surgeons, you know, were you using your hand to retract? And then the other person was using two hands to do the dissection was the. Hand helping. And then the other hand was dissecting. So it was interesting to see some of those differences that were mentioned.

The other thing that was tracked was the number of hand exchanges and most of the procedures had over 10 hand exchanges, yet they still had decreased or time. And so again, this kind of alludes to the benefit in terms of helping to facilitate teaching

and being able to switch operating surgeons while they were not powered to detect a difference.

In terms of the conversion rate you know, again, they did show a decreased rate and hopefully using Hals can decrease the need to convert to a formal laparotomy. So I think this article and my, you know, findings in practice mesh well, I. And you know, the times I am using hand assist are usually for dense inflammatory conditions like bad IBD or diverticular disease obese patient patients.

Typically, when I'm taking the mesentery to be able to have a hand and feel and make sure I'm, you know, really getting a good high ligation. And so, one question I'll pose two questions to Marcelo here to kick off some discussion, but, you know, in defining the intracorporeal extracorporeal anastomosis and the difference there, like, do you think that even matters?

You know, and does it, does it count as inal if you know. It, you're, you're completely lap. Or you know, if you do it through the fantasy, that's extracorporeal. And, and does

that clinically matter? I'm curious. And then you know, the other thing is a lot of these surgeons, it seemed like we're kind of adopting more hand assist.

And so I. Are it, you know, is there bias, selection bias in the surgeons? And while I think this study was really well designed, do you think the surgeons are just faster at how, because that's what they did more and what the practice consists more of. So I'll, I'll have you answer those questions, but great study.

Thanks Tess. So also just to say when we designed it, I went to the zealots and said, what data would you need? And John, if we go back a slide you know, what would you need to have a difference in length of stay or I. Pain management. So I went and got all the data points that they said, well, you gotta track pill counts, you gotta track pain scores, you gotta track all this stuff just to really show.

And they really didn't see a difference. So I hope that the study showed that the outcomes were equal. Now they're even better now, 20 years later than we were then. But I, I, I think the study

was well designed and purposely designed. So that those that didn't think the hand was a useful tool would, would appreciate it.

The question of intraoral versus extraoral, if you do the osmosis with the cover off of the gel port, it would be extraoral if you put the cover back on to do it. You would call it interoral, but it really doesn't make sense. And we already had randomized studies. There are randomized studies already for sigmoid, colectomy, intraoral versus portal showing no outcome differences.

So I don't think there's a real need or a benefit of intraoral anastomosis if your incision is right over the anastomosis, you know? And for the second part is I think if you a good open surgeon. And you know how to use this tool this wristed instrument, the original wristed instrument I think you can be faster because the, it's like five tools instead of just one stick.

And so with a wrist, and that's why I think if you're facile with this you can be

faster and you can avoid the complications So complex. Procedures, total colectomy or bad dive, particular disease, complex diseases, dive particular disease, inflammatory disease or Crohn's. And then patients, and we'll talk about the next study, you know, obesity.

So I think the hand can overcome a lot of adversity and if you end up bleeding, having your hand to put a sponge in and out really, really helps. And so I do still hand assisted today 'cause I think there are benefits in certain populations, but even without it, there's still benefits. And I teach open techniques.

Using hand assist with a laparoscope because I think residents today may not have all the skill sets of open surgery that I grew up with, and so I want them to have them. So I use it for dual purpose because I think there's benefit to the patient, and I think there's benefit for education of residents who now need to learn a whole plethora of techniques in doing it.

Yeah, I mean, I think your thoughts. Yeah. My, yeah, my,

my two thoughts are, number one, from a methodology standpoint, I am really fascinated in these surgical studies. You know, we're enrolling patients right now in cosmic, and so I'm getting to, I. See what it's like to enroll patients in a national study.

You read about the a la carte studies. You read about the AZO 6 0 4 1 studies. You read about Puccini, you talk to the, the s like the real life surgeons who actually enrolled patients in these trials. And now we have someone here who designed one of these trials. And so I, to me, I'm like. And then that's sort of the history of how that actually happened.

And like how did you get the sites and like, where was everybody? You look at those names and you're like, where was everybody in their career at that point? So because these are I think this is what we need, these are the studies and data that we need. So I, I'm like, that's the first part in my mind that I look at that and I'm like, that's awesome.

That's great that you guys did that. And you know, how, how can we replicate that with future studies? That's sort of number one. Number two is we'll get into a little bit with this next study and

then once we talk a little bit more about like. Practice patterns to me, I, I think I am very grateful that I had that background and training with hand assist surgery because I think it just taught me so much about laparoscopy, about open surgery, about hand assist, and that eventually a lot of the print, same exact principles I use for the fi, the instruments that risk but happen to be docked on a robot.

So all, all the same, all the same stuff, and all the same principles. Alright, so let me, I'm gonna talk about our next article. So, this is gonna be laparoscopic colorectal surgery for obese patients, decreased conversions with the hand assist techniques. This was done and published in 2012.

This was done at Cleveland Clinic. So, you know, in, in, and Peter mentioned in, in certain patient populations. Hows may be beneficial. And so one of those patient populations is patients who have obesity. And so in this study, the authors look to compare intraop and postoperative outcomes of Hals and laparoscopic surgery and patients

with obesity.

So this was a retrospective study, so prospectively maintained database patients were enrolled if they had a BMI greater than 30 and underwent either hand cyst laparoscopy or straight lap. They looked at a ti a five year time period at Cleveland Clinic from 2006 to 2011. Conversion rate was defined as in any increase in the length of the incision beyond what was routinely used to complete the operation.

And then the groups, like I said, were compared on operative and postoperative outcomes. And then they looked at cases that were converted. Cases that weren't converted. So for hand assist surgery, a seven centimeter lower midline or low transverse or fantasy seal incision was used for the hand port.

Interestingly, and Tess pointed this out for the last study that they didn't do use right colectomy. So this study did use right colectomy, which I agree with what Tess was saying. I, I typically am not doing or saw hand assists, right sided surgeries, but they did for this case. You know, they also looked at lefts and total

colectomies and ectomies.

And then they described a little bit about their technique, similarly for how sys was defined, but then how straight lap was, was defined, and then all patients had the same uniform post-op pathway in regards to diet pain management and discharge criteria. Right? So they had 496 patients who met those criteria?

86. Were hand assists and 410 were laparoscopic. There were 14 surgeons who were performing laparoscopy. Six surgeons who were performing hand were performing hand assist surgery and only one of them routinely did hand assist surgery. The two groups were comparable in terms of patient characteristics, indications for surgery and really the meat of the paper and the main outcome.

It comes to conversion. So in certain, in the hand assist group rate of conversion to open was 3.5%. And then in the laparoscopy group was 12.7%. EBL was also significantly less than the housed group compared to straight. Laparoscopy length of the incision was shorter in

the laparoscopic group 5.7 versus seven centimeters, who know that actually makes a difference.

And then operative time and post-op outcomes were the same between the two groups. When you look at conversions, so, there were 55 total conversions, 52 in the lab group three in the hand assist group. Indications for conversion. There's no link between the diagnostic indication and need for conversion.

The patients who underwent conversion, this is not necessarily surprising. Had longer length of stay increased or time and estimated blood loss when compared to patients who didn't have conversion. And then there was also higher morbidity without differences in mortality if you had a conversion to open.

So the authors concluded that in patients with obesity, hand assists, laparoscopy, increases the likelihood of a successful. Minimally invasive operation without any real significant difference in length of stay. You know, some limitations of the study retrospective wasn't prospective as with the first study.

So certainly could be influenced by some significant selection bias. In terms of the type of technique that was

used. You know, they didn't control for some of the operative factors that you know, Tess had mentioned in the previous study. They didn't look at post-op pain. But all in all, you know, it still is a good retrospective study that I think adds some important data to know and support its use in certain patient populations.

So, comments gang about, about this study in particular. Yeah, I'll, I think it's a, I think it was a good study, especially in this time. And I think it's important to, to note that just about every study that's been done has shown fewer conversions in the hand assist versus straight group. And it's, you know, why, why would you need to alternate?

Well, bleeding or, you know, a proactive conversion versus reactive, you know, bad adhesions. You, you can use a hand sometimes to help in certain areas. Small bowel obstruction with diverticulitis. I'll talk about that later. You know, so there are things that you can overcome when you have a tool.

I think the key is when you're really watching the video, for many parts, you don't see the hand. If so, if you're seeing your

hand, sometimes you gotta wonder, am am I doing the right thing? Like, I can't see. Usually your hand is in the way, so you do have to practice on some easier cases to gain the benefits in the harder cases for obesity.

I think what's fascinating is when we look at incision site extraction sites, if you do. A large male, their extraction site's gonna be probably five to six centimeters. If you do it with a hand for me, that's gonna be eight. So it's really two or three centimeters Enough of a difference to make a huge difference in outcome.

Probably not. I mean, and so I. You know, on average for a skinny patient, you may not need a hand, but for obesity where you can't feel the vessels in that fat male mesentery cancer cases, you know, I feel really good that I can palpate the IMA and then I can take it and I can take my hand out and put a straight lap instrument in.

So there's also versatility with the current things, and I don't think that comes out, like it's just Hal's and I did a

case yesterday, I don't know how to document it. I did some of it open, I did some straight stick and I put my hand in. I think the, the ability to change from one approach to another should be what every surgeon should be thinking about and not.

Trying to classify it as one thing or another. It, it, it's minimally invasive surgery by whatever method. Tell us, what are your thoughts in terms of this obesity and such? Yeah, yeah. No, I think you bring up a lot of good points. I think I definitely, for that fatty mesentary where it's, I'm doing it for cancer, I like to have my hand in there.

If it's really. Thick to be able to feel, to, you know, feel confident. And just like you said, sometimes I'll put my hand in, take the mesentery and then take my hand out and just use a, a port through the, you know, gel port and, and do straight lap, you know, so going back and forth. I think in this study in particular, it'd be interesting to see a subgroup analysis based on.

BMI, I mean, you know, breaking it down 30 to 35. 35 to 40, et cetera. As we know, this was in I think 2012 you know, a third,

honestly, a BMI of 30 is like pretty normal now, you know? And so, it would be interesting as we're seeing, you know, more and more of this to, to stratify because I think of, you know, a patient with A BMI of.

30 a little bit differently than 45 in terms of their perioperative risks. The, you know, I, I think this paper highlights the decreased conversion rate with hand assist, which we've talked about. And, you know, a lot of both of these studies were short-term, you know, not long-term outcomes. And I think one of the big things in terms of conversion that we, you know, with laparotomy is, you know, the risk of ventral hernia, which is.

You know, obviously for obese patients gonna increase morbidity. So, you know, both of these studies look at short-term outcomes, but there's also some long-term outcomes that we can think about as well. Yeah, I think like, like, like we've been saying, I mean, we're obviously huge proponents of Hannah's surgery, at least having that as a, as a.

Backup. I mean, it might certainly could very well be your primary approach, and I think that that's

great. I, for me, in terms of where I'm at right now in my practice, it's a fantastic backup approach. And so I'm you know, primarily trying to and I think mostly doing pretty much all, you know, elective mini minimally invasive abdominal surgeries, robotic, these.

But certainly my learning curve with robotic, you know, one of the things that I felt very comfortable about was, okay, I am gonna. I'm gonna try and work on the robotic flexor, the robotic, like deep pelvic dissection or, you know, taking up, you know, that, that you know, Crohn's medicine, whatever it is, knowing that I had that house backup, that I could salvage a case if I was concerned about something or if I wanted to make a proactive conversion and then be able to avoid a laparotomy.

I mean, I think that that's a, that's a huge advantage, I think in terms of in terms of patient outcomes. Yeah. You know, I remember in fellowship you shared a paper with me Marcelo, that Dr. Tom Reed

published talking about the use of, you know, hand assist or peak port. So I think that's one of the things as I started in practice, you know, is this patient, are they gonna have a hostile abdomen with a significant inflammatory process?

Should I just do this open? Do I even. Dare attempt laparoscopy. You know, early on I think I did a Hartman reversal and I just did it open and, you know, in retrospect, like, could I have done that lap maybe? And so I think this peak port, peak port paper helps to try to address this conundrum where basically he just describes making a small laparotomy incision big enough for a hand port at the beginning of the case.

And basically right then and there determining, you know, alright, this is not so bad. Let me proceed with hand assist, or let's do the open laparotomy. And so in, you know, I, I think it was 79 patients who had this approach about, I. Half of them had immediate extension of the, to the laparotomy and the other half underwent hand assists, laparoscopy, and only one of those who needed a, a, an eventual

conversion.

So again, just, you know, using this hand assist as a way to help triage patients and maybe you can get that minimally invasive approach. Yeah, and I think it is important to realize that you make a, a lower midline incision. We're gonna need some incision anyways, whether it's that or a fan still.

And I think the thought of just taking a look to see you, you can be surprised. And, and I think more of this could be done by acute care surgeons, you know, maybe in their future, but also with the enthusiasm of robotics. Everything's all about robotics. Well, if, if the Fletcher is hard. And I agree for both, for, for both of you.

Like you can be empowered to do more robotically because you know you have a tool to back it up. But if we don't train the next generation about how to use this hand as a tool for the backup, will it be okay? And we've looked at our recent experience in some other institutions looking at outcomes of left colectomy, the robotic, or hand assists.

The, the and those that started hand assists versus

robotic the robotic group did slightly better, maybe a half day to a day, less length of stay, but had less splenic flexion mobilization. The hand assists group had more splenic flex mobilization, but they seemed to do pretty well. But for those.

Robotic cases are more challenging. They almost all got converted to hand assists. And so I think the goal is avoid the midline laparotomy by one of the method and maybe we should be doing more of this and helping our acute care surgeons, you know, in that realm, John. Yeah, and I, and I think something that I, I didn't really appreciate when, when thinking about making that initial hand assist port, whether that's a fan steel or lower midline, especially in the setting of prior surgery, is can you maybe even start with like a varus needle and a five and the left upper quadrant and then you, and then you look around that way, and that's your.

Peak port, or maybe it's a couple extra fives, and those are your peak ports. And even if you're gonna end up making a faint steel, I mean, you know, opening up a, an incision and then

encountering or opening a fashion and encountering adhesions is always a bit like I. Nerve wracking. So if you can start with a, you know, under pneumoperitoneum and perhaps clear off those incisions so that you then make your, your, your lower midline incision, your pH steel incision, you know, knowing that the, the underlying bowel is well away, I think is a nice option to consider as well.

I totally agree, and I've been doing that exactly like you say John. So I think a lot of good tips for those listening. You know, we kind of have alluded to this, but Marcelo, are you, I know you're teaching a lot of these courses for residents and fellows right now. Are you, are you doing courses for.

You know, practicing general surgeons or like a CS surgeons, like you've kind of mentioned or are most of what you're teaching to residents and fellows? Yeah, so it's really interesting that there's been now somewhat of a resurgence, realizing that this may not be so bad. I. 30 years ago in Europe, especially

when we talked about hand assisted, they were laughing at us like, it's not beneficial.

Even for the fellows, you know, we're, we're doing now hand courses again because they're doing, it's how do you split up the, the colon operations open, you know, straight lap, robotic in hand. And there's some programs where they're not getting exposure to hand. So we do courses for the fellows. Just so they have the tool.

But what's interesting is that Dave Klemen and I just went to Amsterdam, 'cause the European groups are realizing that they are not doing as well with laparoscopy as they thought. And so, I, I think there can be a role, especially for our acute care surgeons to learn some of the techniques for a hand Hartman.

And that actually happened last night. The patient with a darul, with an abscess in the pelvis, had a small bowel obstruction. She was pretty ill going on to pressors. And so the ACEs surgeon asked me, so we made a three three inch a nine centimeter lower midline incision and I was able to break apart the small bowel

obstruction.

We're able to suck out the abscess. And then I was able, I need to mobilize the colon. She had polycystic kidney disease. This is something that I would not have been able to challenge because of the SBO with straight lap. But I was able to do it with a hand, with a three inch incision bringing the stoma to the left of her quadrant.

And so I think there can be more benefits. Teaching for some acute care surgery and avoiding the big hurt for this population. So it's interesting to see that, that there may be some swing back. And again, I think the goal is, John, I think is like a tool for the box. John, we can go all night. We can keep going.

We're, we're here. We're here all night. All right. This has been a great discussion. Let's, let's get, let's get some of our takeaways and we can, we can wrap some of this up. So, TES, why don't you kick us off? Yeah. All right. Consider using a peak port or diagnostic laparoscopy. How can be useful for those dense inflammatory process or patients with

obesity and before converting to laparotomy, you know, might wanna stick your hand in.

Belson's approach. I'm gonna go next. I would strongly, strongly encourage those who are listening, if it's not already something that you know how to do, incorporate this into your toolbox. Okay. We are we need to be well equipped surgeons and not just. Open surgeons, not just straight lap surgeons, not just robotic surgeons, right?

You have to be able to modify your approach as needed. And so it's a great bailout. And then hopefully avoid a midline laparotomy. And then, yeah, you can certainly consider peak port. But then also you know, you can consider doing averis needle in three fives. You know, and try and get a sense of what's going on in there and what do you need to do.

All right. Dr. Marcel take a song. Marc knows I. I think the goal is minimally invasive surgery by whatever method it means works for you and your practice. I think it works for complex procedures. Total

colectomy just the time saving and the colovesical fistula. Why not have a fan still right over it?

Complex diseases, Dr. Guys or Crohn's complex patients, obesity and bowel obstructions. And, and at just a tip, if you're seeing your hand and you can't see anything else, you may not be doing it right. And so come to a course and, and we'll try to give you some tips and tricks to keep it outta the way.

And remember, this is the original Vista instrument, but more than any else. Avoid the big hurt for your patients. Be a open-minded, minimally invasive surgeon and do what's right for the patient. All right, time to wrap up. So if, again, if you like diving into the weeds, you can join us on our Sunday evening colorectal surgery virtual education series.

Check out our show notes for some of the details. It's really been a privilege privilege being able to be a part of this behind the knife team creating content for you all. If you did enjoy this session let us, let us know. We can leave a review. Last time. Gang is behind the knife says until the next time.

Today.