Heine van der Walt

dreaming to see. What are you going to

present to us? By the way, do you

have a good rest with the

administration work?

Yes. What I use the time

before is to send my

emails and so on and also

write up the operation in between

cases because my office

is just downstairs so that makes it

very easy for me.

Our next patient is a 71-year-old

patient. She presented shoulder pain

between her shoulder

blades and dysphagia.

And on evaluation, he was then found to have an intrathoracic stomach, and obviously opted to have it repaired.

So we're insulating it again with our 5mm port over there.

There's the top of the zephyr turnum.

So 15cm from that, we're going to put in our camera port.

There we are.

Now we're working in the media, as you can see.

so you always have to make sure that the camera is very clean

otherwise you have a very distorted picture

right, now we're just going to place our other ports

in the same position as we said previously

does he help you bait the prank DJ?

right, ok let's just go through the port position again

our first port, the 5mm port with which we insufflate

top of the confluence of the ribs

ribs, and that's about 12cm from there. Then we put in, I'm just going to leave a spot

there, then 50cm in the midline, we put our camera port, and this 5mm port is between

these two ports over there, halfway between. Then we put in a port between the xiphisternum

and the rib cage on the right hand side, and our other 5mm port is halfway between two

slightly more lateral. And then what we do is we put in a grasper, to pick up the tip

of the liver and that's to be able to slip in and you can see this if we just have a look here

there's just virtually no stomach over here right and if we pick this up there's our hernia

can't really miss it hey it's very clear all right again you can see these white

marks here this is a long standing earlier for a long time right now what we're going to do is to

to start off and open up the lesser omentum over there. When you open up the bottom here,

just be careful not to hit the hepatic artery. There's the hepatic artery. And then we go

down to the diaphragm. Right, and now we can see the cruz. There's a vena cava. This is

the caudate lobe of the liver. This is the cruz on the right side. Now what we're going

going to do is just to pull this back a bit there's the left gastric artery so you can see

it's actually quite high up into the chest left gastric artery we're going to grab this again

and pull it down and as we've got it down here you can see there's the white line of the goose

presenting itself there so we've got to take that thing from there pull it right out here and then

we're going to expose the white line of the diaphragm there again that's taken down and

And the idea is also to get some air into the mediastin that breaks the suction lock that you've got, these hernias up there.

And this will be a good demonstration case of how to take care of the sac.

Alright, we're going down here.

There's the cruz on the other side.

Alright.

Okay, now what we're going to do is I'm going to take my assistant's grasp, put this on the fatty pad and just pull it like that.

Just keep it in that position.

Not too hard, eh?

Not too hard.

Just going to open up a bit. Again, that's the hernia sac there. Open up over here.

Right, so now all I'm going to do is just follow out the sac.

Now I tease away the tissue from the sac's edge like that.

You see there's the diaphragm. So I just stay on the sac here.

Grab the sac over there. Just pull on the sac.

All you do, don't try and dissect the esophagus, don't try and dissect the stomach.

You can see the cruciate ligament is going down on the stack.

Grab that over there, pull it out, ease that back, just develop the stack.

There you can see the stack again being inverted.

There we go.

Alright, we retake with distance grasper again.

Keep it like that.

and you see I make no attempt to actually reduce the stomach, I just leave

that alone, go down on the sac, you can see the edge of the cruz coming into

sac on the inside there as well, alright, we have to go for the sac again, we just go

Go down, keep dissecting the sac, trying to loosen it off the tissue in the mediastinum.

A bit of blunt dissection.

Alright, now we're going to change that again.

Slip the assistant down to there, all that for me.

Alright, put it out like that, yes.

Now I'm just going to roll the stomach out, close the crux there again.

We're going to divide this sac into two over here.

done now is basically just keep on the sack all the time and loosening it and

now we're just easing that away there in the inside back all right so now we we've

gone with the sack right around now I'm gonna grab the sack here pull that one

there and then with blunt dissection I'm just going to roll the sack

sack, grab the sack over there, sack over there, just roll it out, gentle, dissection,

pull that down, see I'm pulling the sack, yeah, I'm just pulling the sack, that's all

importance, yeah, oh yes you have to, you have to deliver the sack, yeah, you have to

You have to dilive the sac, otherwise you can't repair these hernias.

This is mostly an operation which is done in an election course, programmed intervention.

But in case of an emergency, an acute case, let's say with a volvulus or any other acute complications the patient presents, would you do exactly the same or what?

I'll do the same.

I always try to get the volvulus down by laparoscopy, but as you know, sometimes that volvulus can mushroom into the chest, and you can't deliver it, and the result is that you often have to go and do a thoracotomy to decompress the stomach to be able to return it back to the abdomen, because it's blown up, and it looks like a rugby ball inside the chest.

chest. And of course in South

Africa we know very well what a rugby

ball looks like. Did you watch

the World Cup, Peter? Yeah, by the way, congratulations

for the recent championship.

Excellent. I enjoyed

the match. It was beautiful.

Destroyed the English.

Yeah.

Very carefully loosening these

loose strands over here.

Because you don't want to injure the esophagus.

Yes, you can do it a little bit sturdier.

Who's that doing that?

I'm going to do the same thing.

them yeah uh what i always do with these as well uh peter is uh with these big look it's a big

cavity here you'll see the whole camera is now inside the chest a few things that i can show

you here you can go up there's the pleura right on the side over there the lungs are pushed away

there's the aorta at the back lying over there that's the aorta if you have to watch out for

that if you go up a little bit higher here you find a blue thing and that blue thing is the left

pulmonary vein right same on this side you go up to the Carina then I go up to

the Carina this patient's got a short esophagus so very important to get

proper medium type 2 mediastinal dissection to make sure that you get

enough length on the esophagus we've got to loosen it off the pericardium in

anteriorly and the aorta at the back this one doesn't look too bad there's

the spine and there you can see the pleura on the other side there's the lung right we're just going

to clean our camera sorry i missed the age of the patient 71 okay right now let's just get this out

and then just see a bit of anatomy right now if you look at this this is the sack you see giant

Yeah, and let's go up to the top there, Komnada, right, there's the esophagus, and now here's the stomach, now again, if you try and do a fundoplication, and you put that through there, all this fat and sac goes through there, so what you have to do is, you can see that, hold it, this is the fundus of the stomach,

so what we have to do is to dissect this part off the funnest of the stomach so

we can have a hole and enough stomach to put through when we do our fund application

the fat bed in fact is only mobilized it's not yes I don't excise the stack I

leave it here I'll show you just now why okay are the long gastric vessels they

They used to be short, but you can see how long they are now.

Now you saw I loosened that up till there.

See those two points are getting, coming together there now.

Even in these big hernias, you have to take the short gas sticks.

Otherwise you don't get the proper part of the stomach through.

Then you do an anterior wall wrap, like with the Rosetti-Hell operation.

I pull this open like this.

See now you spread this like a bedspread or like a tablecloth.

like that pull it out like that for me just hold it there not not too hard a little bit less pull

a little bit less okay those are the short gas sticks you can pull on it now a bit very important

to divide these posterior attachments and of course you have to be watch out for the splenic

artery over here it can often lie in your field of dissection got that loose on that side and you

You can see the huge fatty patch she's got here.

Swing that over to that side, like that.

Just hold it like that for me.

And you see, during this whole operation, I never really worked with the stomach or the esophagus directly itself.

My concentration was really on just dissecting the sac.

By dissecting the sac properly, the stomach and the esophagus will come into view automatically.

Right, let me just have a look here.

The important thing is, is the fundus loose?

To calibrate the rep, you said before that there is an NG tube inside, would that be

enough, or is it advisable to pass a bougie?

No, I don't use a bougie, especially in these cases, because this esophagus is shriveled

up inside the chest is lying in zeds and so on and if you try and put in a bougie before especially

before our section you perforate the esophagus i'm just making sure that our nasogastric tube is

there i can feel it i can feel it okay i just hold that like that we're just going to clean

our lens and then we're going to close up it all it what is the solution for the iatoplasty

I use Ticron 1. It's the same as Ethibond 1. The reason why I use Ticron is actually a cardiovascular suture and it's the only Ticron 1 that you can find on the market that's on a 26mm needle because I don't want to use a big needle. I want to use a 26.

So I take my first suture over there, good bite over there, there you can see the subphrenic

artery coming off the first branch of the aorta in the abdomen, it takes a lot of practice

to actually stab it, you can see I'm not good at that, right, so we're just lining up the

people you must also watch out you mustn't pull on the esophagus too hard it it can actually tear

very and separate the muscles very easy all that for me now this is typically the case that somebody

switch your anterior before you switch your posterior because if you switch your posterior

you take a way up you actually cause a lot of tension when you try and come and switch

anteriorly it was very I just put up one at the back that's just to line up the

crudae that helps with that if you don't put it sometimes you just do it in the

wrong way you see every time I do it I put the crudae on stretch you can

sometimes hit that the subphrenic vein there so you have to be careful but it's

not a train smash if you hit it it usually stops bleeding by the time you tie it up

the same with the subphrenic artery over here sometimes you just hit it because

intrathoracic stomachs and the giant hiatus hernias. I see them every six

months for the first two years for endoscopy because they've got quite a

high rate of recurrence and if they just develop a small parasophageal hernia I

bring them back immediately because if we leave it within a month or two that

whole stomach is back into the chest. So I have to do quite vigilant follow-up

for the first two years on these patients.

Do you use the basic score for the GERD score also in these cases?

I do, but you know, the fact is these large hernias very seldom present with GERD.

Some of them don't have any heart, like this patient had no reflux or heartburn whatsoever.

whatsoever, she presented with chest pain and shoulder pain, and she had dysphagia,

that was all, so they very, most of them actually don't have GERD symptoms, they, and they're

usually referred from either the pulmonologist, because they go there because they're short

of breath, or they develop, you know, geriatric asthma, that's what we call it, so they go

there for a lung problem, and then they find out it's actually the hernia that's stolen,

and you know liter and liter off of the vital capacity of the of the lungs and

the patient also because of the big hiatus they lose their diaphragm energy

and they can't breathe deeply so these patients would usually come from either

the pulmonologist or from the cardiologist where they present with

chest pain they usually admitted in the night they then are evaluated you know

So angiography and chest x-rays, and again, during those examinations,

they usually find that the patient has an intertheristic stomach.

So they don't present, and they're never on PPIs,

because GERD, as I said, it's the mechanical effects of the intertheristic stomach

that takes them to the doctor, not the GERD.

But a good clinical examination, would that not lead to at least

is suspicious of diagnosis?

No.

No, not at all.

No, you need a scope or an x-ray.

An ordinary clinical examination won't show you that this thing is in the chest.

And most of these patients, if they get to you,

they've been around to the cardiologists and pulmonologists

for a few years before the diagnosis is made.

That's the usual pattern of referral.

And, of course, sometimes you get them from the casualty department

where they present with acute chest pain and vomiting and those are usually the

patients who present with a volvulus of the stomach in the ER and that's of

course an emergency that has to be attended to quite quickly you can't wait

with him if you scope the patient and he's got that purple stomach or starts

starts going blue, then you know you're in trouble, yeah.

Real big bites on the krure.

Yeah, you have to take big bites on these krure, otherwise these stitches tear out.

These are, you know, look, these krure are so stretched out that they're thin and they're

weak.

And of course, you mustn't tie it too tight.

If you tie it too tight, then of course they just cut through.

You have to be careful.

Is it a matter to re-approximate the krure?

It is a matter to re-approximate the crura.

Sorry, I can't hear you.

It is a matter to re-approximate the crura, not totally tightly.

Approximate, don't strangulate.

But then it mustn't be too loose either.

I'm getting these things together quite easily.

So that's eight sutures in total.

I've heard some surgeons say that they only use one suture to close the hiatus.

I'm always wondering how to get that done, because I can't get that done.

Maybe they do a continuous suture.

Here we are, I think that's the only way you are.

Now, what we're going to do is, you can see this thing is still too long.

I have to cut this over here, otherwise when you put the stomach over it pulls all the fat through as well.

Do you leave a drain in?

Yeah, I was just busy. As I started, you also started talking.

With these huge cavities, I usually put in a drain in the chest.

Because, you know, what happens if you've got a bit of oozing and so on,

with the negative pressure, it's all sucked into the chest.

And you can form a big hematoma there if you're not careful, or even a seroma.

So I would put in a drain just to decompress and just suck that thing flat.

And then once that's done, I usually give them about a day or two, I take out the drain.

You mean in the middest time, of course?

Middest time, yes, absolutely.

They have to drain that large cavity.

At the stages, and even if you do a barium swallow?

I don't do routine barium swallow on them.

I just do routine barium swallows on the re-dos.

These patients start with clear fluids tomorrow, and the day after they go home.

They're in hospital for two days only, and then they start on full fluids.

I keep them on full fluids for two weeks, pureed diet for two weeks, soft diet for two weeks.

At six weeks I do endoscopy, check that everything's fine.

If everything's fine, they go back to a normal diet.

Let's have a look there.

they're a bit too big

so we need one small little stitch

just all that

it is

you've got a lot

lots of fans

unfortunately

they're all males

and they're behind me

and they're behind me and I'm worried

really they are all

astonished

about the surgery

the knotting

the follow up

all the technical details

really fantastic

that's better

beautiful

you see now

look at this

what I do now

is I'm going to put in the drain

but I just want to show you how nice and bulky

this nissen is and this is what anchors

this thing at the bottom over here

and then this is the sack

and what I do is I'm going to put in the drain now and afterwards I put the sack

over there this is peritoneum and when you come back there are no adhesions

that's why I don't take out the sack that's for that reason now I'm going to

put in the drain what I do is I take my 8 millimeter port I put that grasp in

there and I put it across and out the abdomen on the other side then I get I

grab my drain and I pull it back into the abdomen right stitch just going to

You stitch the drain so it doesn't pull out.

In this case, at brachiosophagus, does this one fall in the two stages of operation or not?

I only determine that on the post-operative endoscopy.

Because often you think it's too short, and when you scope them, it's fine.

And sometimes you think, oh, it's fantastically correct, and when you do the endoscopy, you see that you're actually short.

So, I only make that decision at the post-operative endoscopy to see exactly, you know, where the Z-line is and have we reduced the stomach completely.

I don't make that decision now.

Cut.

Voila, no mesh.

My colleague, which asked you earlier on, and he's surprised, no mesh.

Fantastic.

And also, not one single drop of blood.

Yeah, there was two drops.

Right, Piero, I'm just going to write up my operation and just tend to a few chores and

then we'll see you now again for another case.

Okay.

In how long?

Sorry, how long?

One hour, you said?

In how long?

How long are we to change?

Half an hour?

Half an hour.

Yeah, 20 minutes, half an hour.

Half an hour.

Excellent.

Okay.

Good.

I'm waiting for your report anyway.

Okay.

See you.

Bye.

Ciao.

Ciao.

Ciao.