VAN DER WALT

Hallo.

Yes, hallo.

Ready?

You're ready?

Tell us what about to do.

Ja, this patient had an intrathoracic stomach.

She was operated in 2014, the first time.

And then she presented two years later,

again with a diaphragm opening with reaneation.

And this is now another two years down the line

and the patient came back symptomatic again.

en op endoskopie het hulle nogmaals een parasophagel hernia, so dit is nou die typieke ding wat jy

sê met die groot hernia's, die intertherasieke hernia's, en daarom, as jy een intertherasieke

lichaam doen, moet jy hulle met endoskopie volgens 6 maand vir die volgende 2 jaar volgen,

want as hulle recurreer, sê hulle normaal gesê dat jy binnen die eerste 2 jaar,

wanneer hulle last gaan of nie, so ek het die patiënts, al die patiënts

are always in a surveillance program

to make sure that

we pick them up early.

Because if you pick them up early, you can

at least try and salvage it.

If you leave them and you find out too late,

then of course that whole stomach sits

inside their chest again, and you start

right from the start.

And the incidence of recurrence with

intrathoracic stomach is three times

higher and more

than you see with

ordinary

patients.

Please, can you tell us once more, the ports of entrance, especially also pointing out your technique,

how, when you put the virus in, to mobilize, to pull down the skin from the ribs down towards the umbilicus. Thanks.

Ja, ok, wat ek doe, kom uit, ek, baie sieso, ja, dit is die brief, ek sê vir jou sieso, wat ek doe is, ek neem dit in en ek

neem dit over soos dit, op die rib hd, as jy dit uit neem, het die skyn incision,

het die skyn incision, het die skyn incision, het die skyn incision, het die skyn incision, het die skyn incision,

on the skin and you inflate the abdomen then the incision is going to sit there far away from your

rib now it's on the rib cage over there right clean the lens and again now we've got our ports

the liver retractor port over there the assistant port the camera port five millimeter port

8 mm port, jy kan sê dat ons die liwer daar gekoek het, want dit is een behoorlijke groot liwer, nie groot

deel, een lang floppie liwer, jy houd dit, ek gaan dit gewoon vir my sê,

ek dink so, ek dink so, soms met die heel groot liwers, uh,

speciaal as hulle floppie en hulle hierover vlieg, dan wat ek doen is, ek het

in die rechte laterale aree van die abdomen,

in die 10 mm poort,

en dan gebruik jy die vandretractor.

Ek gebruik dit gewoon met die floppy livers.

Die big livers, die een beetje sorotik is,

is mooi en stief,

dit stijgt uit die weg.

gepikte, symptomaatik?

Of wat kind van testies het jy gedaan?

Symptomaatik?

Symptomaatik, en sy went vir die chest x-ray,

en sy gesuspecteerde een hernie,

Toen het hulle een endoskopie gekom en op die endoskopie het hulle hierdie groot parasophagel hernia gevonden.

Hulle het nie enkele pH-studies of so gedoen, want reflux is nie die probleem.

So hulle het een hoofdpijn gebeld?

Ek het jy verantwoord.

Hulle het een hoofdpijn gebeld?

Het een hoofdpijn, ja.

En terwyl hulle gesprek het, het hulle ook gebeld van dysfasie.

Eerder nie wanneer hulle eet, maar wat hulle normaal gebeld het,

of when they start eating, they're fine

but as they continue eating

they become fatigued and the swallowing

becomes more difficult and difficult

and that's usually because as the

stomach becomes fuller, the

parasophageal hernia starts

pressing and pushing on the esophagus

which causes dysphagia

liver attractor a bit over there

if we can get better access

look quite flimsy

Do you have the same feeling?

Yes, they're soft.

They're soft.

The previous patients adhesions were quite

they were much more firm than this one.

Let me just see over here.

We have battle.

Does the 3D vision help you a lot?

A lot.

I'm very spoiled.

Once you've worked on 3D

it's very difficult to go back to 2D.

I do my inquinal hernias

with 2D because there's not enough

space for the 3D camera.

But you get spoilt with the 3D, let me tell you.

It really makes life easier.

But I think the most important thing about the 3D is,

it doesn't cause the eye fatigue that you see with your normal,

the picture is much softer,

and your eyes don't get that tired.

Maybe it's also because we're wearing shades, you know.

Because that's the first thing I actually noticed with the 3D,

is that in the end of the theater list, especially a long theater list,

my eyes are not as tired

dry my hand

dry my hand

dry my hand

big parasodial hernia

yeah, it's quite big

it's stuck

let's open it up on this side a bit

dry my hand

I think we did it in 2004

not 2014

this patient, yeah that's right

but that's the last operation but she still has gore texting oh yes yeah that's right

still your camera does she have already an empty tube in situ yes she has a ng tube

we'll check now whether it's in position you can see these white sutures here that is gore

text that was actually done if first operation was sent elsewhere and they used gore text again

Again, that's where the Parasolvigilionia climbed in, eh?

You can see it over there.

Yes, it's very clear.

Can you recognize in this case, once again,

the transverse vessels as a landmark on the esophagus?

I think this was probably put over that anyways.

So, it's very difficult because these sutures are in there now.

Closer.

You see, here you can see again

how we are winning length

on the esophagus,

because often with these intrathoracic

stomachs, they've got this fat little

inimitous short esophagus,

and as the esophagitis

clears up, and they've now got a nissen,

over the next year or two,

all that edema goes down,

the swelling goes out,

the esophagus elongates again,

and I don't do collis nissens

for short esophagus anymore.

What I would do is to do a nissen,

do it as best I can, leave the patient

for one or two years, and then

bring them back and do a second stage operation

to get that stomach down into the

chest, and I haven't done

a colis nissen for many

many years, and this technique

it's definitely better to do two

operations, than to do one colis nissen

because believe me, the clinical

results of a colis nissen

are notoriously imperfect

and bad, and you know

we are talking of treating a functional

disease, you know

we end up

a gastric cripple because

of a symptom of heartburn

just isn't right.

So when do you stop actually pulling down

the esophagus

to start then with your

hernia repair and

the nissen? Well I always see

I can get as

much as possible of the esophagus loose

like over here.

As you loosen it, you gain length.

The maximum I would

go is up to the left

pulmonary vein.

wat jy soms kan sê in die kase,

het sitte over daar,

en het is eindelijk blauw,

we are not that high up yet,

but that is I think the limit of your dissection,

I think if you go higher than that,

you are probably going to,

ok, just clean the lens,

you are probably going to injure the bronchus,

or even the left pulmonary vein,

so I think that is your landmark,

that you have gone high enough,

and that is quite high up into the soffel,

into the middest eindem,

Right, now this, let's just see how are we for length in here.

Right, now this is now sitting quite low down there,

although it's not that low, eh?

But I think we can definitely give her a better position.

Okay.

This is still all fibrogic tissue, isn't it?

Ja.

You can see there are the sutures.

So we're going through the suture line of the nisse now.

Okay, that's that side loose.

There's the fat pad.

Can they quiet down the people outside please?

There we go.

Mark, bottom of my lens.

Let's just vent this and get rid of the smoke.

Prof, you said you're using an NG tube, I think size 18.

Size 18?

Yes.

That's correct.

What is the drop back using a larger bougie as it was done in an open Nissan in the past?

Just repeat that question Peter.

Yes.

jy gebruik een saas 18, wat een kleinere

pype is, dan

een bougie, een saas 56

of 60, even, bougie dat was

wat is die drop bag, of jy gebruik

een griep?

Ek gebruik nie, ek gebruik nie een bougie

die nasogastie kube

as ek dit inlaat

dan ek

ek gebruik die plus die 1 cm

in die buik

as jy een bougie gebruik, dat

sal ongeveer saas 50 bougie

48

48, 48, ja,

but I don't like using a bougie,

because the thing is, you know, it's different for each patient,

and I like looking at the anatomy as well,

because sometimes you get a very big person,

with a thick esophagus,

or a thin esophagus,

and you have to compensate for those,

those different scenarios,

so I never use a bougie.

There's the posterior vagus,

there you can see it, eh?

Alright, come back,

Just checking the light.

Might be one or two pieces in here.

That's okay.

Let's just have a look at this.

There we are.

Right here.

There's another piece of the future

sitting in the esophagus itself there still.

Right, let's have a look at what we have.

There we've loosened the stomach.

Here we've got the esophagus with a bit of length.

and there we've got

a big garage door

and again you can see there's been anterior

closure, but this is the weak

spot once again. There you

can see it. That's where the stomach went

in. You can see, look how weak

it is over there. Right, let's just

open that.

You start always with the

anterior repair, eh?

Ja, one switch posterior and

then anterior. Ja, you must do it early, otherwise

if you do it later, there's too much

tensie, dan kan jy die aantere repair nie doen, so jy moet dit doen voordat jy die posteriële

as jy die esophagus neem, die pleura, nie om daar een ontslag te doen, jy kan dit nie help,

help het, want soms,

speciaal met redo's, die pleer is

adherent to the

esophagus of the fundus.

So, is a given, that you're probably going,

if you do redo's, you will get

pneumothoraxis. That's very

common. It's actually to be expected.

And you can't, there's nothing

that you can do, because I mean,

the pleer is so thin and flimsy,

that if you pull it down, it's going

to tear, no doubt.

No doubt. By the way, Mr. Neithitis,

what does our pleer look like?

hoeveel stokjes, ja, nou, verspreid vir ons heel, heel laag, dit soort knop, want dit is

heel interessant, ok, dit is een groot waarde van mense, jy weet, veel diensten, ja,

goed, wat ons doen is, ons maak een loop naar die bodem, die neemhaal naar die bodem, die

kom net van die buitenkant en dit gaan naar die bodem, ons pak dit op, ek neem die en ek

put dit door, dan supineer ek en ek maak my loop naar boven, dit kom van die buiten, dit

gaat door en die knie lood het naar boven, dan maak ek dit door, so loop

naar boven, pronate, pronate, supineer, pronate, loop naar boven, knie lood het door, supineer,

knie lood het naar boven, soos dit, ek sal dit in laagmoes doen, of meer laagmoes

Ek probeer dit langzaam te doen.

Alright, let's put this suture.

Now what we're going to do,

is to pick up the,

and this is important,

this suture must lie across at 45 degrees like that.

It's no use just doing anterior sutures there.

You can see what happened.

This is the area that closed up,

opened up, that is the weak spot.

So what we do,

we put the esophagus on a stretched anterolateral,

that's the top of the esophagus there,

so dit is meer of minder die aree wat ek gaan doorgaan, en ek neem een groot biet,

en ek swing my neel omhoog, neem dit so, kom over die kruis, dat is daar, en kom

door die kruis daarboven, en nou kan jy sê dat die Sushi is ligging so,

we het een klein hematoma daar, nou wat gaan we doen, must be an oblique,

must be oblique, ja, jy kan sê dat is 45 degrees, nou ek neem my loop, die bodem,

soos jy nie lood kom vir die bodem, pak dit oop, breng dit oor,

soos jy nie lood kom vir die bodem, pak dit oor, en dan het jy hierdie

skweerknop, jy kan dit sê, en dan pak ek hierdie oor, en ek kapsies die knop,

soos dit vir die sliepknop, en dan gebruik ek dit nie lood, om die aree te pak,

soos ek my soos jy nie lood, anders gaan dit vir die bodem, en jy

so dat jy geen goeie proksimaatie het, anders moet jy die instrument daar aansluit en ons het nie

ekstra instrument en tuurlijk is daar nogal een doel, ja, so ons moet hier naartoe gaan en dit sluit, wat

mooi is van dit knotting methoed, wanneer jy knotting aan die top of aan die bodem is, is het

alweer makklik om goeie proksimaatie te het en nie in die goeie positie te sê, daar nogal, as dit nie is, dan

jy dit op die en jy sluit die knot neer, plik daarna op die en dit klink die knot

how big is going to be the gap that you leave here in this anterior repair uh well my gap i actually

tube is not in uh i can feel there's no nasogastic tube here so we have to get an

het dit om dit te inserter, want dit kan nou weer heel misleidig gaan, goed, nou, daar

het dit, daar het dit, goed, stel dit na, stel dit na, daar is dit, goed, goed, dit is hier, bedankt,

ok, dit is diep genoeg, goed, net so dat, nou, ek wil gewoon gaan en make sure dat my

My opening at the back is going to be fine.

It has a little adhesions there.

I'm going to take them out of the way.

A little bit bigger.

Put in a small one at the back there.

The upsides are not.

Down.

It looks small now, but it will be right by the time we finish with it.

Right.

You can see that we've, just hang on before you take.

I'll give it to you.

You can actually see that this nissen was down here.

we are going to put it up there now,

hold it,

not too hard,

just like that,

nice fresh stomach over there,

that's better,

right,

probably a bulkiness in this,

that's fine,

again this is a full thickness,

stitch on the stomach,

and then on this anterior part of the lower,

below the vagus,

and then on the other side,

that's right,

Same thing, full thickness again.

Right.

And important, it just lie there, it mustn't pull back.

If it pulls back, that means

it's too much tension.

Then you must go and mobilize more.

Take down more short gas sticks.

I must say that the stomach

lies very comfortably there.

Very comfortably, yeah.

You see no tension whatsoever.

Ah,

that's not very nice.

That one in there.

That one up there.

There we are.

Nice full thickness of the stomach.

Over there.

What's left of the vagus.

Quite frankly.

Right, let's have a look there.

Yeah, you can see we've actually won quite a bit of length on the esophagus.

Not too much tension.

It mustn't pull back so it's completely up like that because that means it's too much tension.

You must be able to see this little, I always call it the little diamond.

short floppiness

there, one centimeter

that's good

there we are

and anteriorly is all closed up

anteriorly is all closed up

yeah, for sure

for sure

does this magnesium sulfate

really work for the pain

for the pain, for stop

yeah, how it works is

we've got lignocaine

20 ml en dan 2 gram magnesium sulfaat en die magnesium sulfaat werkt op die nmda

receptoren in die peritoneum wat die modulatoren van peritoneal pijn is as jy gewoon

normaal lokaal gebruik het, dit maak echt geen groot verandering, jy kan tenminste een 20 minuut

effect, if you lose that

use the local

with the NMDA

or with the magnesium

and you block the NMDA, then of course you

have a much longer effect

and it's probably 2 to 3 hours

before the patient will experience

pain after the operation, so

there's a much longer interval

and they complain of much much less

shoulder pain, that's why we give it

alright Peter, thanks

that's the end of our show

listen, mask on the other

for Prof. Palazzini, we must

really congratulate what all you have shown

us, what you have seen, what you have learned,

amazing, all bloodless

field, difficult cases,

interesting cases, we really

enjoyed it, thanks very much

for your effort, what you have done,

it's absolutely fantastic, thanks

again to your team, to the

nice nurses,

which you only see the

sunglasses, no more,

but enjoy

now a good braai and a beer,

thanks thanks again very much i don't know whether we can see again tomorrow morning but maybe you

said it is quite not possible but really we would love to have that in case just let me know

okay how well okay peter okay you keep up i'll speak to you one of these days

thank you very much to everybody eh by your donkey by your bank right okay