Alright, everybody, we are back. We had to switch scopes, and the reason why we had to switch scopes is we're going to be doing some endosuturing. The current device we have is the Apollo Endosurgery Overstitch, and this requires a 2T therapeutic scope. So we have different kind of setups and devices that come with this kit. One is the cinch that we'll use at the very end. We have the suture that we will be using. And then we have the actual overstitch itself, and it has this kind of neat plunger or kind of grip that if you cue in real quick at the tip of the scope, you can see as I close this, I'm driving my needle and releasing, okay? So click and drive the needle, click again, it's gone. So this will go in, if you see, to one of the working channels on the tip of the scope, okay? And we're going to turn on our scope, and I'm going to show you, hopefully we have this in the right spot, let's see, just give a second, scope, there we go, all right, perfect. Yes, okay, so you can see where the needle's coming from, the direction. It's usually always that 10 to like 4 o'clock, and so that's what it looks like on the scope. Click, needle's driven, click again, needle's out, okay? I want you to go ahead and look at the tip of the scope again real fast. This right here is big, okay? It's really fun to do this procedure, and there's just two times you always need to remember this is closed, and that's at the start where you're intubating, and at the end when you're pulling it out. If you put this down the esophagus with this out, you are due to cause a lot of injury to not only the esophagus and to the G-junction. We always go down with this closed, and we always come out with it closed as well. While you're in the stomach, it can be open, all right. That is on the end of the scope, and we're going to show you now how to mount this to the scope, okay? Why don't you pan into where the working channels are, the ports right here. This has a little bracket that requires a 45-degree angle. You can't just clip this on. It doesn't work that way. I look for this little ridge right below the caps, and you're going to go at a 45-degree angle, even maybe even 60, and you're going to feel that little friction, and it's on, off, but you cannot, like I said, it has to be at the right angle. You're almost going to have to hook it on, and it's on, okay? Now we've got our overstitch in place. We have to now put on our needle. Here is the Apollo needle, and this has to be done with a lot of care. It's very fragile, and so you're just so gently going to put this on, you'll feel a little click, and then it will come out, and this will be your needle. We can actually take it out of this paper as well, and it comes wound, and you can just undo this if you want to help just unwind that, and this, what I always say, goes on the right port that you're working with, your right, so we're going to untangle it all the way, keep it nice and straight, and we are going to go on the right port, and we're the one closest to the clamp, and we're going to go down. Let's go to scope view now, and we're looking for the suture to come out, and if you look at my hands in the picture-in-picture, you'll notice I'm getting closer to this white part of the up here, closer, and that is where you know you're going to be getting close to where it needs to be, so this will actually go in. Click. See how it came out? Now, what I recommend is just kind of going in and out, and what that does is give you here, we're going to let go of that real quick, it gives you a little slack, sometimes it's, there we go. See that little slack? That's what you want, okay, so now the next most important thing is you want this needle, which we see that very tip of the needle right there, right on the other side of the loop of suture, that cannot be out. If you close this right now, you're going to bend your needle, okay, so you need this out of view, so I pull it back, if you look right here, I have it about, I don't know, one inch or two centimeters for our Canadians in the room, and so now it's in, I'm closing the suture, or the needle, and this is going to be very tactile, and as you guys use this in person, this is really the most important parts of this device, is you're looking for just subtle little tactile clues that you're in place, so what the next step is, now the needle has been placed, or the needle has been closed, the suture is back, I'm going to slowly push this forward until I feel a little click, you can see the suture coming, and I just felt that click, so now if I was to open this, it wouldn't go to the needle driver, I have to release it, and this blue plunger is where you release it, you only want to do this at certain times, and we're going to go through this, but now that I have it loaded onto my needle driver, I'm going to transfer it by just plunging down, and just slowly coming back just a little, you don't have to yank this out, only a couple centimeters, and you'll see now, as I open, I'm now ready to throw a stitch, now I recommend always in my practice, to do the first one outside the body, so you can troubleshoot it while you're not already intubated into the esophagus, so you can look real closely at the camera, I am not going to go down like this, remember guys, I can close this, and if you look on the scope, I'm still on it, okay, so don't worry about if I open it up, I'll show you how we transfer it again, but now we're going to go down, and this is definitely a case where you want to have a nice jaw thrust, this is a big potentially traumatic device to the esophagus, to the upper airway, the cricopharyngeus, this is a big device, okay, okay, so we are down, there's our nicely closed perforation that we did before, and so now I'm just going to pretend I have a lesion in front of me, that we're going to suture, okay, so like I said, I have not transferred it back to the other side, I'm still on my needle driver, so I'm now, I feel comfortable opening up, and you'll see this on the scope, if you watch my hands, I'm clicking, opening, I am on the needle driver, so what I'm going to do is just line it up, we're going to play pretend, like I said, and just get a nice bite, kind of want to wedge this tissue in, get a nice area there, you're going to see me, now drive the needle, okay, I've driven back, you can see that I've gone through the tissue, I am now on the right side of the, on our orientation, so now what I need to do, excuse me, Mike, is go and grab this, so I'm going to push back to come with my little plunger system, to come grab this suture, you can see, I'm there, I'm feeling for that tactile, and I just felt that little click, and now I've grabbed it, and I'm just going to pull it back into me, so see, I've now thrown a stitch, oh well, it went through the tissue, it's okay, that's okay, we'll try it again, nope, it might, it came off, okay, all right, so let's see what we can do now, that was not supposed to happen, but that's okay, we can always troubleshoot this, so it went through, okay, looks like we didn't get the greatest, but let's see what we can do, oh, I didn't grab it, that's why, it's still on, okay. There we go, got it, felt it, and then we're going to come back. We got through that, did it go over? Yes, there, that time it worked. So you can see I've now thrown a suture. That first one I think I just went through tissue, that's all. Probably not going to happen when you have a human, it's just what we deal with. So you can see that nicely we've gone straight through the tissue. We're on now to the next part, which is throwing the second suture. So you can go over, and you really want to try to not get yourself tangled up. You want to try not to throw a suture and make a figure of eight in between. You don't want to necessarily go in between here, all that stuff. So you kind of want to have an organized plan. I tend to try to do like a zigzag pattern, and you can give yourself a little bit more slack. What's important is that you're not putting tension, if you look at my hands, on the needle outside, or the string outside, because that will tighten this up, see? So I'm going to give myself some slack, whatnot. I still have this, okay. So again, and it's just a matter of repeating this process. So am I going to do this? Am I going to drive this here? No, I'm going to ruin my needle. So I got to get this needle now all the way back in. Still, this is too far. If I close this now, this is going to bend my needle. It's going to make transfer way too difficult. So I'm going to go all the way in to the device. I can no longer see that. And if you want to give yourself even just like a half a centimeter more, just to be sure, go for it. So now we're going to transfer over. We're closing. And now I want that tactile feedback again. I'm pushing in slowly until I feel a click. There's my needle coming out. I felt the click. Going to release it now. To release it, I have to plunge this down. So I'm plunging down and just slowly coming back just like a centimeter or two. The tendency is for fellows or people new to this device is to re-ank this out and it just makes things messy. So now if I open up, this is going to be on the other side on the needle driver now. See, now we are ready to throw our next stitch. So now we just line it up. We see, say we want to close right, we're going to take our next bite here. Clicked. We are now ready to grab it again. So pushing out slowly, we're going to go catch our needle now. I felt it. Pull it through. Open up. And you can see we've now thrown our second stitch. And Eric, when you're doing this in real life, what role is your tech playing? Do you sort of operate all of these moving parts? I will be honest, this is very much physician-led. Your tech is definitely getting things ready in case this breaks down. So if you need a new needle, if you accidentally drop the needle before you're done suturing, making sure they have all this stuff available to you so you can quickly troubleshoot this. Definitely the tech is involved on this last part where we will go to cinch. We'll get there when we're done suturing. All right, so let's throw another one. So again, we want to go ahead, bring the needle out. So we do not close this again. Remember, guys, we do not want to bend this. What we want in order to switch sides, we're going to pull it back, get it out of visualization. We do not see it, right? We can close now. Bring the plunger and the needle up. You can see it coming in. I felt the click. I'm now going to transfer it by plunging and pulling back just a little bit. And I'm ready for my next bite. So let's bring it over. Let's say over here. Let's get away from our clip. And essentially this is a running suture. Do you typically go until the suture is done? No. So typically you do about four to six bites or throws. It's really until you feel like you've gotten enough of the circumference. A lot of times if you have this big circular defect, I'll put this down. You can go to my hands. So I'll suture, suture, suture, suture, suture, pull it together. And then you'll see the pattern start to close up. And then we cinch it down and release the suture, basically. All right. Go back to scope. We'll throw one more. And we'll go ahead and get this guy. All right. See if we can get something a little bit more on this side. Yeah, yeah, yeah. And here we go. We're going to go. So let's double check. Let's just make sure we don't have any of the needle out because we don't want to bend our needle. So the needle's right there. We want it out of view. Drive. Go transfer. So we're pushing this back in, pushing this back in. I felt that tactile feedback, that little click, tells me I am now touching the needle driver. I'm ready to transfer. Plunge. Release. By just pulling back a little bit, we've now transferred over. We're ready to take our bite. Took our bite. Let's go grab the needle. And we're just slowly going until we feel it. I felt that little click. Now we want to take it away from the needle driver by just pulling. Got it off. Open the jaws. And if you give yourself a little bit of slack, there we got our next bite. Okay. Do we have any questions so far? No questions. No questions so far. That's okay. All right. So say we're done. Let's say we've closed our defect. And we want to now, or we've sutured everywhere we want. We're pulling it together. We like where it is. What you do to get this needle off of your device is literally you're going to be dropping it, except, or plunging this and dropping it, except now you're going to have the needle driver open. Because that way it doesn't go onto the needle driver. It's going to drop in front of you. So now all we do is plunge and pull. There's our needle. Okay. So you're going to be taking out the needle device. But you don't want to take the thread out because this is important for when it comes to cinching. So we're going to put this to the side. I'm going to have you hold this for a quick second. And this is the cinch. And I don't know if any of y'all are like fly fishermen or just enjoy making knots, but it has this little orange device on there. And it's used to help get it through this little itty bitty hole. Because the thread is going to go through this and out this little hole where the Apollo sticker is coming out of. And it's going to just pull it through to make your life a little easier. If this wasn't there, yes, you can do it. It's just going to take you a little bit of time. So what you do is this circle up here, you're going to put the end of the needle thread or the suturing thread through. Oops, sorry. Sorry. I was just standing too far away. It's okay. You need your glasses again. Sorry. Pull it on through. So now this is on that other side. This is going to pull it by just through that other hole by just see it collapsing. It's going to drag it on through. And you can just grab that and look, it's now on the suture. So then we're going to, and I'm going to actually have you do this portion. All right. We're going to feed that down. And you want to just, that's a good view. And your tech or whoever's helping you with the cinch is just kind of keeping this not tight, not loose, just kind of in a stable position. This being the suture thread. And if you start seeing too much slack come out or anything, you can pull back a little bit. That's fine. Go ahead and clean your lens for me, if you can. That's okay. And this will start coming out. There you go. So what I want you to do is put that white part on top of that fold. You want to be over where you actually did your suturing. Yeah, so like I wanted to put it above where the sutures are. The sutures are all right there. Yeah, so try to get that on top, you might have to just torque a little bit. There you go. So go ahead and push that out. Let's get on over. And where do you want to do this is you the goal of this part of the cinch is to get out to some, some ribs, so keep pushing it out. Keep pushing it out. Keep pushing it out there. Those are what you're looking for. Those little spiral ribs. And that's what you want. Okay, so now we're going to pull this together. Keep I want you to push that out, push that out more. So you're going to tighten things up, tighten things up. It's good. All right, so now pan over to my hands for me real quick. I'm gonna have you hold this a little bit of tension on this if you can. While keeping that tight. Good. So go ahead and zoom in on my hands for me. Let's switch to my hands is show you guys. Okay, good. So this has this little bracket. This thing comes out. You open up, you just kind of have to open up, it's, it's like a spring a little bit so you just open up this thing drops out. Okay. So what you're going to do is you're going to see this cinch start spiraling, and when I completely close. It's going to cut the needle. Okay, and it will have our suture completed. Okay, so let's go on over to the scope and you can see my hands as I do this. So you'll see and we're just going to try to keep that nice and tight. You can see the cinch coming down and twisting and cutting and doing its job as I pull in more and more he kind of often I like to tell people that they need to use like two hands with this. See it spinning it's getting ready to go getting ready to go. There it is. Now if you back away. Let's pull this back. You have now dropped and cut your needle really nicely. Excellent job. Alright, so any questions on this. Nope. All right. We can just put this away, and I'll take over the scope real quick just to show them real quickly. Where what this will look like when you've dropped and cinched. I can see where you. Part of it is you got this big old thing on there. So if you there it is to the right. It's kind of all puckered down now but it did a job it close up there it is. Okay. So you can see now I've sutured this up really nicely. So you can see how it's come together. was a closure. All right. Perfect. Now, if you were say you accidentally dropped your needle. You know you plunged and pulled back at the wrong time, and your needles out there, you would just cinch it, and then load another needle on and you just start the process all over it again. So just to remind people and we'll go back with this steps. Let's pretend we have a suture on there. We've given some slack. We do not close it like this, that will break your needle, or your, your, your suture. I'm always going to bring this back until we don't see anything and so I like to think is the. I was taught the, the car is now in the garage, so we can close the garage door. But if the car is slightly out. So you have your your hood out. You close the garage door you're going to dent your garage, or your car, excuse me, and the probably the garage. All right, so you want the car all the way in, we're ready to close right. Then we go. We're going to transfer by bringing the needle up, we feel this little click. And it would, in that case, bring it on over. Okay. This guy. All right. All right. We are actually I think you're not supposed to do this with the needle on or without needle on but okay, this is a good point. We now have this in a closed position, we can come out. We only come out with this in the closed position. All right. If you guys think of any questions on this in the interim please let us know we're going to start setting up for our next device.

endosuturing

Apollo Endosurgery Overstitch device

therapeutic scope

plunger

stitching technique

cinch