Speaker 1: Today, we're going to be talking about the making of microlearning videos for transplantation. The objectives are to identify a key portion of the operation, film in the OR, reduce the video to less than three minutes, and have faculty narrate with teaching pearls. The first part is identifying a key portion of the operation. This can be any part as small as how to make the incision to as complex of how to make an anastomosis. Next is filming that particular portion in the OR. At first, we consent all patients. We explicitly state that we will be using this for teaching purposes and it will be broadcasted on social media. The next key to filming the OR is we use a stabilization device. We find this important for smooth video taking and it also gives the comfort level of everyone in the OR that you're not going to drop the camera in the field. And the last thing is to really get the operating room staff on board with what you're about to be doing. You take up a lot of space in the operating room and it goes a lot smoother when you've talked to them beforehand. Next it's really important to reduce the video to three minutes. We broadcast this on social media and people watch it on their phone and the attention span of less than three minutes is optimal. We spend some time discussing with the faculty in order to trim down and get the key points. This only requires basic editing software. We use Adobe Premiere, that's just because what we're familiar with, but iMovies or one of a multitude of softwares will work just as well. And finally, we meet with the faculty and have them narrate teaching pearls. The key point of this is for them to identify three specific teaching pearls and when they are talking about the video, it's important that they don't just narrate the steps, but they often highlight unspoken maneuvers that they're doing in their head at an attending level. So trainees can learn these great tips and tricks for when they are doing the procedure. So here are examples of microlearning videos which we have used in broadcast and we hope others will take part in this.

Speaker 2: This video will review our use of the right subcostal incision with midline extension for liver transplantation and abatability surgery, landmarks, retractor placement and positioning of the liver to allow exposure to the right retroperitoneum. We like to place the subcostal portion of the incision one to two finger breaths below the right costal margin with a generous midline portion. This incision is made with a 10 blade and extended with electrocautery. We use the omni retractor as our self-retaining retractor. We use a three post system. The two posts are placed immediately under the arm bars at the level of the lower chest with the crossbar positioned to retract mostly towards the head rather than towards the ceiling. A angled bar or hockey stick is used for the lower border and we use this articulating elbowed bar for the left side of the incision. Here you can see the upward retraction of the body wall retractors, again using care to retract towards the head rather than up towards the ceiling. The liver is then retracted using a sweetheart retractor to allow exposure to begin the portal dissection. One critique of the use of this incision is that by limiting the incision to the right side of the abdomen, it is difficult to expose the right retroperitoneum, but as you can see in this video, the liver is retracted by placing it under the abdominal wall and retracting it towards the left upper quadrant, which gives great exposure to the right retroperitoneum. This is done instead of lifting the liver out of the retroperitoneum. We really like this incision, the patients like it, it avoids dividing the left rectus. Remember the landmarks for the incision including a generous midline portion, retractor placement that is upwards more than towards the ceiling, and tucking the liver under the abdominal wall to expose the right retroperitoneum. Good luck.

Speaker 3: Today we're going to go through a video on an end-to-end anastomosis of the portal vein during an adult liver transplant. Key concepts are assessing the clamps and the retractors so that everything is lined up and it's easy to sew, appropriate location of the liver so that it's in its anatomic location, and just the standard technique of sewing this in an efficient way, consistent way and use of the triple stitch. And then we'll talk about the air knot. So as you can see here on the video, we have the two ends of the portal vein sewn together and we usually cut it so we say it's just the right length. So usually you have to trim a good bit off of the donor liver if you have a lot of portal vein because you don't want this thing too long, you don't want it too short. We try to be very careful about putting the liver in its anatomic location. So I usually put two cold laps behind the liver, one on the side, and it looks like we're pulling up a little harder on it than usual here, but it might just be a really small graft. But nonetheless, you have to make sure that you have it in a location where it's going to sit because otherwise if this gets too long, it can be a problem. So notice the person sewing, which is our fellow, it's probably Meredith, is push, push, pull, consistent. Same thing every time. So the attending who's helping her knows exactly what to expect. And she's about to do the triple stitch. So we're sewing from the inside. This is the back wall of the portal vein. And we'll just kind of basically keep doing that, but we'll take also the front wall. She just did it there and came in, came out on the outside now. So she can just keep sewing, doesn't even have to stop. It's just an efficiency move that we use in transplantation for big anastomosis. And you look at the retraction, we have kind of two body wall retractors up. We have a sweetheart on the liver pushing up on a little bit. So we have a great exposure. And then we have three retractors down. It takes four hands to do an anastomosis. So if you're holding retraction or doing anything else to the other hand, just call someone in to help you. And they can follow because, you know, once you kind of start doing this, you can't stop. And then when you come out of the corner, I usually think of doing two stitches, kind of the same size, so to speak, so the corner doesn't leak. And then I start assessing any size mismatches. And in some transplants, particularly in like pediatrics, it can be a massive size mismatch between the veins. So you have to make that up as you go. So you don't make that up on the corners, but like right here, for example, you take one or two perfect stitches that are just the same size, and then you just assess your size mismatch and make it up as you go. You can kind of see the person following just puts it under just enough tension so that it comes together, but doesn't cinch it shut, which is really easy to do for any venous anastomosis. And you're thinking here when you're sewing this, just don't back wall it. So you see your tip, you'll put up the wall and you'll see your tip with every single stitch from the inside so that you're not, you know, you're not catching the back wall. If you catch your back wall, then it won't work. When we tie this thing, we leave an air knot, usually at about half the diameter of the portal vein. So that's the portal vein anastomosis during a liver transplant.