Tricks - Imperforate Anus and Rectourethral Fistula

Today, I'll talk about the elaborate surgery for male impreus with the rectal ureteral fistula, especially how to dissect the fistula to prevent post-operative cyst formation due to the radial fistula. Dissection of the valve and the prosthetic fissure is still challenging. Even in bowel fistula, we have to dissect the fistula up to the red line to prevent residual fistula without injuring nerves, prostate, urethra, and the sphincters. Recently, we developed novel technique to measure the length of the fistula, thus allowing a labor surgeon to know exactly how far, how far to safely dissect distally for a complete cystic excision. There are 29 male with imperference after a new technique. One vescal fistula, 14 prosthetic fistula. 9 bulbar fistula, 5 no fistula. So 23 had rectourethral fistula and were studied. I will show you one of the cases of prosthetic fistula. He had a right transfer colostomy soon after birth. A disal colosculum demonstrated direct urethral fistula, and during some procedure was performed at the age of 7 months. I'll show you, this is our preferred track position for prosthetic fistula. During the laparoscopic facial dissection, the fistula was dissected, taking great care to avoid injuring the vas. A fine flexible colonoscope was inserted into the anterior rectal wall. The endoscopy of the rectum allowed both the fistula, or this and the level of laparoscopic dissection to be observed intraluminally. I think the, ah, the bottom video also should be moved. So interluminally we can observe. How we are dissecting, where we are dissecting. This is a colonoscopic view. Next, a fine catheter with a calibration was inserted through the opening by the la surgeon, whilst another surgeon performing cystoscope observed how far it emerged. At or near the Vermontum. By doing so, the lap surgeon could measure the inside length of the fistula between the fistula, opening, and the urethral side orifice. Thus, the actual length of the residual fissa to be easily calculated. Hey Yama, let me stop you for one second. Mark wanted me to tell you that on some of your slides that had 2 videos, we made 2 slides out of it. So could you, could you back to the previous slide? Yes, I, I want to explain the, uh, we'll go back, but Gama, before we play it, I just want to explain because some of your slides had 2 videos and we can only play one video at a time. OK, so we made 2 slides every time you had that. OK, could you back the previous slide? Keep going back, Mark. And could you start this video. As you can see, the lax surgeon, he set the catheter with calvulations from the Erectile side of the orifice. Then we can measure the length, residual length of the residual fistula. Could you move to another Nexus video? You know, At the same time The surgeon who was doing a cystoscope can see the tip of the catheter, which was inside it, from the rectal site of the fistula. As you saw the uh in the previous slide, then. If the length of the resal fissure was longer than 5 millimeters, the rectal end was further dissected toward the urethra. Using a mucosectomy. The mucoectomy to prevent injury of the prostate and the urethra. This procedure was repeated until the length of the residual fistula was shorter than or equal to 5 millimeters. The fistula was ligated, tied, and excised. Could you start the video here? Mark, so start the video here. There's one video here. Is there supposed to be a second video, Yama? No, I don't think so. There's one video here. We're watching the video. Oh, you're watching a video? Yeah, you're snaring with the endo loop right now. Now, now, now, now I can see the video, yes, OK. We have to repeat the procedure until the residual fistula is less than 5 millimeter, then we tied and excise the fistula. Hello? Next, uh, I'll show you the, uh, one of the cases of bulbar fissula. Can you see the slide? This is Ballabafiula. Yes, yes, we see it. Yeah, we see it. Yeah, I do this through the use of tube. You know, for bulbar fistula, it is very important and very advantageous to obtain as clear a surgical field of the deep pelvic floor as possible, otherwise we cannot operate. I do this through the use of a tube tube vasostomy, which decompress the bladder, nicely and opens up a clear view of the deep pelvic floor. This is the important procedure. Troker position for rectal bowar fistula differs from that for prosthetic fistula in that right and left strokers are placed much closer to the telescope compared to prosthetic fistula. This is also key for bulbar fistula. There is a new device that allows the telescope to be adjusted to face any direction from 0 to 120 degrees interoperatively, and it allows the sergeant freedom. Choose the best view without disrupting a dissection. In order to Me sorry, despite the increased difficulty in handling the forceps in this position, it allowed the tips of the forceps to reach. Deeper and to reach the vulva urethra, which is located deep in the pelvis. In order to measure the length of the Bellafissua. As you saw in the, in a previous slide, we did the same procedure, to measure the resal fistula. That is the same procedure in the same as a prosthetic fistula. Then, after the bulb fissua. Was dissect free, the fistula is tied and excised. After the fistula is tied, a catheter is again inserted until it gently probes the tied fistula. As shown in the video, thereby allowing the surgeon to, could you, back to the previous video. Yeah, we'll go back. Yeah, we'll go back and show it. This is a very important, ah, video. A catheter is again inserted until it gently probes the tied fistula, thereby allowing the surgeon to reconfirm that the residual fistula length is shorter than or equal to 5 millimeters. We can check from the urethral site. The fistula is already tied. Then the catheter didn't go more than 5 millimeters. So around 2 to 3 millimeter. This is our results. Here are results showing the first eight cases from the initial measurements of the rectal to urethra orifice, the fistula was 1315, 1210, 1521, 10, 5 millimeter respectively. The 7 cases required further dissection until the fistula shorter than or equal to 5 millimeter, but the case 8 did not require further dissection. During cystoscopes, normal saline reflux into the pelvic floor. Through the fistula in 6 cases, this is interesting, indicating the fistula is large, however, there is no reflux in 2 cases indicating that the fistula is very, very narrow. All are well after mean follow up of 2 years, with no evidence of diverticular formation owing to resal fistula on graph, urethrography, or MRI in all 23 cases. All dissections were uncomplicated. And the post operative courses were unremarkable. The residual fistula from rectal site to urethral cyt much longer than expected. Our new technique measuring the exact length of the fistula facilitates a safe and a complete excision of the fistula, thus reducing the risk of postoperative diverticulum formation due to incomplete fistula excision. Thank you for your attention. Thank you, Yama, and uh let me just make a comment. I, I apologize. You know, in Yama's original talk, he was showing two of those videos together so you can see the two views simultaneously, which really. Explains the technique and, and unfortunately, we couldn't do both videos, but I wanted to point out that that's really where you better understand exactly this technique. I loved it. I thought, uh, I've never used this. I'm wondering, for those of you out there, let's first open it up. Uh, if anyone in the virtual faculty wants to make a comment, raise your hand and we'll call on you. Um, otherwise, I'll open it up to the studio faculty here. Um, and actually, before I do that, I know that Doctor Jafar, are you on the phone? Doctor Jaafar All right. I know he was on the phone and he had a question. If you want to call back in, Doctor Jafar, we can let you ask your question to, uh, Professor Yamataka, uh, Bob, did you have any comments? Yeah, I've, I, I absolutely tremendous, and I think, uh, one of the, it, this isn't trick, trick of the trade. This is like 50 tricks in one presentation. There's so much, uh, in here that's, uh, super interesting. I, I, there's a couple of pieces I have. Certainly one is, I mean, how do you find this many, uh, prosthetic, uh, Uh, fistulas to be able to test this on, which is great. I think the lesson to me was how long this fistula is when we, when you actually, uh, dissect it out. The technique of measuring it is fantastic. My questions, I think, are more, when do we think you, we can use this as the general laparoscopic public? There's a number of skills here that are, are fairly advanced, particularly as you got to the retro, uh, the rectal bulbar fistulas. Um, and when is the crossover to doing it in a traditional posterior approach on these very low ones, more advantageous? It looks like the prosthetic ones, so it may be a bit easier, but bringing in the endochameleon type things and things like that are, they're demanding for people. And I just wonder what you think of the general laparoscopic public, when should we be doing this? Thank you for your comment. Firstly, uh, you know, as you can imagine, balder fistula is, you know, dissection is very difficult. So I recommend the vesical and high prosthetic fistula first and. But in a case with a prosthetic fistula, I think as far as You know, labor surgeon has a, you know, training for You know, gallbladder removal or other, you know, fundamental technique, I think, uh, uh, they can do that. But, uh, if the, the key for dissection of the fistula is the compression of the bladder. So I have a, you know, many experience of, uh, uh, urology. So I'm familiar with the technique of, uh, a cystoscope and, uh, inciting the, you know, tube cystostomy. We call, ah, you know, suprapubic catheter if, ah, Uh, la surgeon, the technique is still not good enough. I think I recommend insert the tube vasostomy first to. Comp for complete decompression that allows You know Give us a good view of the pelvic floor. Then I think, ah, for dissection of the prosthetic fistula it's, ah, I think, ah, they can do that, but, ah, maybe for bulbar fistula dissection. I think, uh, you know, a labor surgeon needs 5 to 10 cases of the, ah, prosthetic fistula, then they can challenge to bowel fistula. But as I mentioned before, the troa position should be very, very close to the, ah, telescope, otherwise the tip of the instrument cannot reach to the deep side of the pelvis. So I mean, ah. tip of the catheter cannot reach to the bowel of fistula. Excellent. OK. Any other comments or questions? I know Jack Langer wanted us to poll the audience to see who here is doing laparoscopic anal rectal malformations. So please go ahead and answer that poll whether or not you're performing laparoscopic, anal rectal malformations. And then Mark, after each of these tricks, if we could also put a poll up saying, do you use this trick? And if not, the second poll, would you use this trick? So we'll do that as well, um. I think, uh, yeah, Jose, go ahead. uh, Yama, that's awesome as always. Do you, uh, do you do other, uh, traction sutures or other stay sutures on the bladder? Is there stuff happening off the screen that we're not, we don't, because you focused on the more distal part? Yes, correct, I think it's often that we use the, uh, you know, traction sutures, and do you know the LA LA hair closure needle? Yeah, we use 2 to 3 traction sutures to bring the blood up. There, there was, there was a question from, uh, Jeffrey Pence. Is a right transverse colostomy typically constructed in your practice? Do you do right transverse colostomies typically, um, and he says it would go ahead, uh, Yama. I do because You know, some surgeons make the, uh, you know, sigmoid sigmoid colostomy, so, and I found sometimes uh we, we cannot, uh, uh, make the, uh, you know, enough length for periphery of the rectum because the, uh, sigmoid colostomy fix the, you know, I don't know how to say the, uh, sigmoid colostomy fix the uh. Uh, rectum and the colon. So we have to take down the sigmoid colostomy to, for, you know, putting it through the, uh, distal end of the fistula. Um-hum. That's why I prefer a right transfer colostomy. You make a comment? Yeah, go ahead. Yeah, so, um, Just on the topic of where the colostomy is done, I, I think there are advantages and disadvantages to a transverse colostomy versus a sigmoid colostomy. I, I prefer a sigmoid colostomy, and I think if you do the sigmoid colostomy very proximal in the sigmoid or even at the descending colon sigmoid junction, uh, you will have enough length to, uh, to do a pull through even for a high fistula. I, I guess I wanna be, I'm sorry, you wanted to say something, Ya? Yeah, but, but how did you find the very proximal of the sigmoid colon at the time of the operations when you are making colostomy? How do I find it? Yeah, how to find out the, uh, very proximal side of the sigmoidal sigmoid to make the, uh, proximal sigmoid. Yama Yama, I'm using laparoscopy sometimes to uh to help to make those initials. Oh, you're using the laparoscopy to make the coloscopy original colostomy so I can see exactly where I am. And if I do it open, I, I find the traction point along the descending colon and make sure I'm close to that point. Yeah, I make the left lower quadrant transverse incision and just pull out the sigmoid and figure out which end is which and just go proximal. Sharif Emil, I see you typing stuff. Did you want to make a comment? Sorry, Todd, I missed most of the presentation because I'm having a lot of, um, difficulties with the program shutting down and rebooting all the time. Um, we, we're just making a point about a transverse colostomy really having too many problems, um, both in terms of, uh, urine absorption and infection and prolapse that I, I think it's uh, I would bet if you polled the audience that. A very small minority would still be using transverse colostomies at this point. OK, Mark, can we put a poll up? Um, who is, are you, are you using transverse colostomies? Um, and then we can pull the audience on that. Um, I, I go ahead, Tom. What's that, Jose? Raise my hand. Should I do it on the line? I, uh, I just wanted to say, I think even with the, um, a sigmoid colostomy, um, it, it's, it's possible, uh, to place your ports and work around the stomas without having to take them down and do the deep pelvic dissection. So I have not found them typically to be a problem, and I wonder, Yama, since you're putting your ports so much closer to the umbilicus, if it becomes even less of an issue with those deep, um, uh, bulbar fistulas. Sorry, sorry, could you say, could you say again the question? A sigmoid colostomy on the left side with your, as you described your ports for the for the bulb, yeah, you're right, yes, yes, you're going to be more midline anyway, so it would seem to me less whether you have a, yeah, you're right. That is another reason I don't like the sigmoid colostomy because if there's a sigmoid colostomy on the left side and you know it would be an obstacle for inserting the truck cars. Actually that's not really a problem. They, yeah, you can just go in the left upper quadrant and go around lateral to the colostomy. It, uh, it, it's not an issue. I wanted to, um, to challenge this technique though. Just I, I know everybody's like, uh, you know, really positive about it, but I. I think that for a prostatic or bladder neck fistula, you can do that dissection without this technique and get very, very close to the end of the fistula. I think you're right. If the, uh, you know, labor surgeon is getting familiar with the, you know, aneurysm laparos aneurysthal malformation operations like you, I think we don't need this art technique, but for balva fistula, I think. You know, I feel still we need these procedures, and that's probably true, but I would question whether the laparoscopic approach is the correct approach for a bulbar fistula. It's, it's far more difficult. I think it's more dangerous. The technique you've described is extremely complicated for the average pediatric surgeon, and the PSARP technique is easy for those patients. And as far as I am aware, there really isn't any convincing data that the laparoscopic approach. Results in any better outcomes for Balbar fistulas than the peace arpis does. The reason why I simply, you know, stick to the laps procedure, even for bulbar fistula, uh, simply, I do not want to cut the sphincter of, you know, anus. I, I just, I just do not want to do damage to the muscle and the nerves for sphincters. Yeah, I, I get that, but, but where are the data? Yeah, I feel, you know, we have, we have to be that. That's the age-old, uh, that's the question that we all don't know. Yeah, Bob, and if, uh, I'm with you, I think you're asking a lot of someone to be doing these very low ones, but critical to this is getting a good fistulagram at the beginning. Yours were very pretty in this. Do you have any tricks that you do to get those fistulagrams so nicely? Cause that can make a big difference deciding what, what you should do. So are you asking how to do the colossgram? Yes, I mean, do you have a, yeah, I think. Yeah, colostogram is, you know, very important to, for studying the uh laparoscopic dissection. So, some, sometimes, uh, if we cannot get the good view for fistula, I think I repeat it. And also sometime before operation, I do colonoscopy. If There's a, you know, doubt whether the patient had a fistula or not. We can do colonoscopy through the transplants colostomy, and also we can do the cystoscope. Sometimes we can combination of colonoscope and the cystoscope before operation if the colostogram did not show the uh nice anatomy of the fistula. Yeah, that's great. Cause I think in the general world, that the lesson would be, at least to me, is that, you know, doing the high ones are, are, it's very helpful to have your laparoscopic approach. Getting low, I think the PSARP is still, you know, for many of us the way we should be thinking and it's trying to decide beforehand before you know which one you're going to do. I, I'll just add to the, the cholostogram. It's, uh, we, we combine, uh, Uh, VCUG and cholostogram at the same time. So if you put the dye in from both sides, usually you can see the fistula pretty clearly. The other point I just wanted to emphasize that Yama made, uh, earlier, but I, I wanted to make sure that it's not lost, and that is how important it is to have an empty bladder when you're doing a laparoscopic, uh, anorectal malformation repair. And sometimes, uh, when you put the Foley in at the beginning of the case, it goes into the fistula and into the rectum, not into the bladder, and you may not know that until you're in the middle of the operation and then you actually, I did one the other day where we came across the fistula and, hey, there, there's the Foley, it's actually not in the bladder. So, I think, um, it's probably a good idea to cystoscope all of these kids at the beginning of the case, make sure that the catheter is actually in the bladder before you start the case. And also when we are doing the cystoscope, we have to, you know, you know, inject the saline. So the compression for the bladder, we need, uh, uh, you know, tube tube vasostomy. Otherwise, you know. Bladder will be filled full with uh, filled with the celli, so we cannot see in the pelvic floor. That's why for val facial dissection, we need a tube of vascostomy to decompress the bladder, especially when we are doing cystoscope. All right, uh, let me just, uh, we're gonna go on now to your next presentation, Yama, and let me, uh, tell the faculty such as, uh, Suad, I see you typing in the presenter area, but no one can see that. So if you could go ahead and type your comments or questions in the participant chat system, then everyone can see what you're saying. Also, we, Suad, I'd love for you to call in so we can talk to you and hear your thoughts, uh, on, and your comments. Uh, so Yama, why don't you, uh, go ahead on to the, uh, And by the way, just to let everyone know that we are simulcasting this in Spanish, so, uh, we will put the number up there, uh, again, uh, the Spanish translation, it's scrolling across the top there if you wanna call in. So, uh, Yama, why don't you move on to your trick for thoracoscopic TEF repair. Mhm. Uh, next presentation is next for the thorax repair of the, uh, tracheoesph fistula. And a We already, uh, presented the, uh, this technique in the, uh, in this journal. 2 year old boy. Tracheusvag fistula, as you can see, and the coil up of the nasal tube. And a For thoracoscopic repair of espal reasure, I feel we have to check the length of the gap between proximal and the diesel. distal esophagus, and I think this, uh, you know, X-ray is a bit, uh, you know, funny, but, uh, uh, I don't know why. But anyway, the, uh, this is not the gastric tube. This is a bronchoscope done by anesthetist. Anesthetists can find the orifice of the fistula. Then I asked anesthetist to stop. Then take the X-ray. So this gap would be the, this is the tip of the proximal fistula. I'm sorry, this is the tip of the proximal esophagus. This level. Is the. Proximal site of the distal esophagus. So gap is, in this case, gap is around one vertebra. So what I'm doing, ah, for rakov to repair in all cases. And when This is a distal esophagus, this is a trachea, this is a clip. To close the tracheoesophageal fistula. Majority of the sergeants. You know, divide the distal esophagus completely, but I don't do that. I leave one quarter of the fistula. And I'll show you later on the video, the reason, because if we divide it completely, the distal esophagus can be retracted cranially and also anastomosis would be difficult. So, You know, there's a fixation of the distal esophagus as you see here, because I left one quarter of the fistula uncut, so When we are Doing a faster. Easy to get the mucosa as you see here. And also, even for proximal esophagus, this is the tip of the partial esophagus. I don't cut. All of the tip of the perm esophagus, I left 125 to 15%. Of the You know, cap, maybe I, I can say the cap of the proximal esophagus to grab. This part by a pair of forceps because I don't wanna grab the anesthetic site. Also, if there's a, you know, 1 or 2 to 3 gaps, we can assistant can. Pull the uh proshima esophagus cranially, sorry, caudally, you know, using. The cup of. The proximal esophagus, this part is uncut. You know, that in the conclusion, our technique is useful at the time of the anastomosis during a thoracic repair of a trachealis fistula, and also I have a video. Mark, do you have his video? Yeah, we're gonna show the video in a second here. They're loading it up, Yama. Um-hum. Oh. Yama, which, um Which stitch do you put in first? Uh, in the middle of posterior patient anterior wall in the middle. I used to be, I used to be putting the first stitch on the, on the edge, but I found that in the middle is much easier, right, especially with this technique, yeah. OK, we're going to roll the video. I cannot, I cannot see the video. It's coming? It's a little window. I can see the video in a different place. Can you see the video? Yeah, yeah, I, the, the audience is seeing it fine. You're just in the backstage, so you're seeing a small view. We're seeing it perfectly, I can. OK, but small, that is a very small view. I faster trucker is incited by the not open technique, by the uh uh I use the uh optical truckers. Then this is uh this slide shows the uh this video showing me a dissection of the fistula and. Sorry, I cannot see, ah. Yeah, fistula is clipped. Could you start the video again? Yeah, we'll show it again. Huh? This is a this. Hello. Oh. Video didn't show the Now video showing you the dissection of the proximal esophagus. Look carefully Dissect the uh trachea and the proximal esophagus, and this is a clip for trachea of a fistula. This is the important part. I don't divide. Completely. You sell esophagus. And also this is proximal esophagus. Start cutting. But I don't remove. Entire tip of the proximal esophagus, leaving 1/5 of the tip of the proximma esophagus. Dissection of the proximal esophagus. So now, You will see the first stitch. I you see a 6450 PDS. Here. I grabbing the, uh, you know, Cup of the Uncut pork smell esophagus. And this is a Dial Esophagus. We have to Take the mucosa, otherwise the patient will have a postoperative stenosis. Again, Grabbing the cap of the proximal esophagus. And you can see the mucosa. Of the proximal esophagus nicely. Because of the Then I Divide. The turkey fistula completely at this stage after. 1 or 2 stitches. And after 2 to 3 stitches, I divide, uncut cup of. The proximal esophagus. So what? You know, virtually I don't touch the side of the anasmosis. In the proximal and distal esophagus. That is my technique. Great. Uh, so I want to talk about this, uh, in a second, but I wanted to give just one housekeeping thing. I see all the faculty, you're upset because the video is so small. You have to understand no one else sees it small except you guys because we're in the backstage production area. So Yama, they saw a nice large magnified view of your video, and we saw that video a few months ago in September, uh, and I tried it since then, Yama, and I loved it. It, it was, uh, it worked great. I, I, it's. I would say that it, uh, it was plus minus. I, I, I thought it worked great by keeping traction on it, but I wasn't sure how much I needed it. It, it almost felt like it, it, it, it was just as easy in the, in the cases when I, uh, cut it and grab it and stitch it. So, I probably will do it again. I'll probably, uh, cause you don't hurt yourself. You can leave that last little bit. See if the stitch sets up perfectly. If it does, you take it. If not, you cut it and then you do it. So I think there's no reason to cut the entire fistula when you're dividing through it. So I just wanted to open this up to the uh virtual faculty first. Um, David Vanderzee is joining us now. David, can you hear us? Yes, I can hear you very well. Thank you. Thanks for joining us, and Doctor Vanderzee is professor of pediatric surgery and head of the department of pediatric Surgery at University Medical Center at Utrecht. So thank you for joining us, David, what are your thoughts on that? Have you ever used that? And, and if not, what are your thoughts on it? I think it might be helpful to, to leave the fistula partially connected to the trachea in the beginning. Uh, personally, we do not do it because we think it's, uh, uh, we use a transfixing suture to close the fistula to make sure it doesn't come off. Uh, and we never use clips because they tend to, to, uh, hook behind the, uh, the suture that you are using. Um, so if we, if we have a Uh, uh, uh, a type C anastomosis, which has a considerable length. We usually put in two sutures and, and then make them into a sliding knot and slowly bring them together, uh, dividing the tension between the, the two ends of the esophagus, uh, and then ultimately, uh, finalize the, the posterior anastomosis before, uh, I call it, uh, putting through, uh, a tube and, uh, closing the anterior wall. Um, at some time, if you have time, I, I, I have a, I, I uploaded a video of how we do our type Cs, but this is Yama's birthday, so I don't want to interfere too much. Well, uh, yeah, we can, we'll show that later actually. Um, but I, I, I do want to show that uh TEF video so we'll get that loaded up. Um, I want, does anyone else have any uh comments about Yama's technique? Before I make a comment, no one, OK, so, um, Mark, we put a poll up, it looks like the polls somehow are not really working because I don't think everyone's answering it. Well, we have 50% on all the polls, so there must be something funky, um, so unless we have an exact divide in our audience on, on all opinions, only two people are voting, so we wanna ask everyone to vote, and if you're voting and it's not working, let us know so we know our polling system isn't working, um. What's that? Right. So we have to check in. Please, everyone go ahead and answer and let's see if those numbers change. Um, so I, I would curious who out there does thoracoscopic TEF. So if we can put that, are you using, uh, are you performing thoracoscopy with your TEF repairs? Um, Mark Wolkan presented an interesting technique from Atlanta where they put a a a stitch, but somebody's phones ringing there. Uh, if we put a stitch through the abdominal, through the chest wall, through the proximal end, through the distal end and back out through the chest wall, and they hold it up as they do their anastomosis, just one more way of doing, uh, of setting up the two ends together. Um, but you know, and I think in the spirit of a trick, I mean, this is one that you think, jeez, is there any downside? No. So it's just one to put in your armamentarium and say, hey, give it a go. If it can help you, great. If it doesn't, it's one of those that there's no loss and it may be an, maybe an aid. That's a great point. That's a great point. And unless, uh, as David said, you don't clip, uh, you're, that wouldn't be the only situation. But if you do a clip. I, I, I think you're right. I think you could still use this with the transfixion stitch. Why not? With your stitch, you wrap it around both of it, yeah, OK, um, I'm Jeff Blair here. Um, this is very interesting. I, I'm just wondering if we're in a limbo stage here, if in the next decade we're going to actually see mechanical devices actually put down through the upper pouch that will mechanically grab and seal the lower pouch. Um, it might be thoracoscopically facilitated, but I think we're, we're actually sort of in that just emerging from the dark ages of repairing oesophageal atresias, and in the not too distant future, they'll be mediated with imaging techniques, perhaps plus or minus thoracoscopic, but just my two cents. Yeah, OK, with that, we're, uh, Sue, I see you're here. Can you hear us? Yeah, actually, finally I managed to get in and hear you through the phone, so it's a great discussion actually. Thank you very much regarding the, well, I've just joined the discussion now about this vigil atresia, and what I did actually, I clipped the fistula. And it was very easy for me to find the fistula laparoscopically. Imagin like I find it's much, much easier, and you can appreciate how much you, you have to go without leaving a lot of. A esophagus on the trachea side, so it was much easier laparoscopically. However, dissecting the upper, the upper segments of the esophagus, it was a bit difficult, and I think the difficulty was just, you know, how to handle the esophagus without really making a lot of A damage to the esophageal wall because this is what you need for your anastomosis. So it was a little bit of handling, but it's managed well. So I think it just needs some tricks how to pull the upper, upper esophagus, the segment of this upper esophagus, so that it doesn't get damaged. OK. Uh, can I just make a comment from somebody who started doing these, uh, a year ago and have just done 3, so I'm sure I'm way behind most of the people on the panel. And my experience so far has been the first half of the case when I'm doing the dissection and dividing the fistul. I'm thinking, oh, this is fantastic. I'm so glad I'm doing it this way. And then as soon as I start to put the esophagus together, I'm thinking, why the heck am I doing it this way? So I'm still trying to figure out exactly the best way to go about it, but if people can just comment about this clips issue, because I know Steve Rothenberg uses clips quite routinely and many others, but we've had several instances where clips seem to erode or be implicated in recurrences. Um, so I'm wondering if what the experience of people are, uh, in terms of how they ligate the fistula. Yeah, I can answer. I, I can tell you that uh I've had that too, a clip erode into the esophagus, and I don't know if it, if I would love to blame it on the clip, but I don't, I don't know if you really can. When you look at Steve's data, who clearly probably has the largest data, largest experience, he's never, he's never had a clip erode. So I hear what you're saying, Sharif. I've had a problem too, and it must be something in the technique, because when someone is using clips as much as he does, he's never had one erode. You wonder if it's technique or it's actually the clip. Are they metal clips or the locks. Um, so I'm gonna answer that and then we'll go to Yama. So, um, I use the metal clips, uh, that's what he uses as well. I know a lot of people use the Weck Hema lock clips. I've tried that almost 2 or 3 times and every time I put that clip applier in, it's so big, I can't see as well as when I'm using the metal clip applier. So that's why I don't use it. Plus, if you put it on and you don't like its position, it's not really easy to take off, um, Yama. Yeah, I think the key for clipping the esophageal fistula, I think if we clip very tightly, it will erode the muscle of the esophagus. So I think when I clip the fistula, I just try to oppose the clip. I think it doesn't cause the erosion, but if you clip very tightly, it will crush the muscle and erode it, and it causes a recurrence of the fistula. That's what I thought. I don't know. I don't know. I'd have to, I'm not, I'm not convinced, but I hear what you're saying. I, I, I, I squeeze it pretty tight. I don't want it falling off. So, uh, but, uh, uh, a good point. Um, let's, uh, I think unless anyone else has a last-minute comment, we're, we want to take a break. Um, so I want to see if anyone has a comment to make. And then we will revisit this later on when we show David's video. So let's take a 10-minute break and we'll come back, uh, with, uh, Doctor Abello, uh, presentation. To all the faculty, please leave your cameras on and sit tight. We'll be back in 10 minutes.