Heide Van Der Walt

het bykie op die tafel self.

Right

Ok

Our case is a

male patient that presented

with quite a long standing

history of achalasia

He was evaluated with

manometry, I think he came with

a barium swallow as well

and on the endoscopy he had

the typical findings of achalasia

and also on manometry

klassieke ekklesia.

So we've got our patient here,

we're now going to tilt our table,

feet down,

hard off,

hard side,

stop,

and, ja, that's fine.

Ja, die hoogte lyk al gerecht.

Good.

Nou moet jy een beetje nader kom,

kom hier so,

oop ons op die beik,

staan onder,

Onder, kom staan hierboe.

Ja, ek kan hier.

Jy moet daar ons verstaan.

O, doktor, dit is ons hoekse.

Ok.

Right.

Focus en op jou beek, zoom in.

Nog.

Nog.

Nog.

Raas he.

Right, now the placement of our ports, we're going to use a five port technique.

That's the Ziffy sternum over there.

That's the rib edge over there.

The rib edge over there.

as jy kan sê, so ons eerste port is gaan

op die ribbeide, ongeveer 12-14 cm van die

toekomst van die ribbeide, nie die bodem van die Ziffi sternum, maar die top van die Ziffi sternum

so ons gaan daar een klein incisie maak, en dit is gaan

incisie gaan, net vir een 8 mm port, maar ons gaan insuflate

with a 5mm

Al het die geboorlik soe by ons wat praat nie, ja.

Right, we're insufflating the abdomen to a pressure of 15 millimeters mercury.

That's got quite a big belly, this guy.

Oh, yeah, maybe you should time me up.

kan ons sien hoe

binne siste rief

doek die vast in die

Zuid-Afrika, good

right, now our next port is going to be

for the camera, and that's about

15 centimeters from

the top of the Ziffy

and that's going to be a 10 millimeter port

ek sê dat dit so begin

maks goed, ok

we let my hand ook af hier

there's our camera going to go in now

hou my nog buiten hoor

buiten, buitenkant, ok

Ok, dan gaan ons volgende poort tussen die camera poort en die insufflasie poort.

Dit sal halfwege in so'n semi-lunar halve cirkel en dit sal een 5mm poort weer.

Dan gaan we dit in een poort, ek wil net sê hoe groot is die liver, o, dit is mooi en groot.

We gaan dit in een poort in die top hier, dit is tussen die rib en die ziffiesternum

and then half way between those two slightly more lateral

in the mid auxiliary line

would be our another 5mm port.

Then we're going to swap the 5mm port here for a 8mm port

and the reason why I use a 8mm port is that a

20mm or 26mm needle can easily go through that.

You don't need bigger.

Right, so this is our configuration.

A 8mm port in the left hypochondrium

10mm camera port in die midline

15cm down

a 5mm port between

these two ports, between the ziffie

and the rip cage over there

we've got a 5mm port and a 5mm

port in that area on the

lateral side, right, now we're

going to put in our instruments and

elevate the lever

there we are

right, we're doing

we're using an Olympus 3D system

as you might have gathered

van ons spektakels wat ons het.

Hy het een mooie big floppy liever.

We het hy eigenlijk

om te verloos een beetje waard

voordat die surgery.

Omdat hy,

ondanks sy dysfaseur,

hy was verloos

en hy is niet heel groot

en hy weid 115 kilo.

Ek gaan die Olympus Thunderbeat

en my instrument

is die Storz Clickfix.

Nu gaan we

to open up the pars flacida or the lesser omentum there's a little artery over there we're just going to

cauterize that all right there we are good right now there's the caudate of the liver that's

overlying our landmarks over there so i'ma speak swop yeah i'll say there we are good

Goed, nou gaan we die aietis open, hier is een, ek gaan dit neem, dit is een beetje vat, dit is in die rechte plane daar, daar kan jy sê die posteriëre vagus koming door,

ons gaan in onder die laai daar, dit is ons laai, dit is waar we moet gaan,

Right, just open up there, there you can see the posterior vagus nerve again, open up there a bit, get that down, right, now we are dissecting down the crux on the left side, we are going to pick up the esophagus a bit there, divide the tissue over here, and loosen up the esophagus, we will do that a bit better,

Ek het hier nogal veel vat in die esophagus, dit is die lipoma daar.

Ja, dit is die totaale verandering in die seksuele plek,

in verandering met die hiatus hernia.

Daar is die nerve.

Goed, ek gaan jy een korte gase neem.

if you do uh if i do a heller myotomy i usually do it to pay uh if you do a door you probably don't

need to take a short gas six but i found that if you don't take them the the door actually

gives you quite a bit of tension on the hiatus area and it's sort of like misformed it's

I never get a good position

if I don't take down

a short gas six.

So we would routinely take a short gas six.

That's fine.

There we go.

What do the father say?

Die?

Oe.

Ja.

Nou, jy het eindelijk een beetje indruk as jy nie.

Ja.

Nou, probeer opstaan.

Ja, en jy het druk nogal erg, nie?

Alright.

Alright.

Ek kan nie worde sê nie.

Piero, we have difficulty hearing your voice.

I'm sorry.

Oh, my hearty me, the length of the mouth to me.

I usually do at least 5 millimeters proximal, usually much more,

and 2 distally.

So, I abolish the lower esophageal sphincter completely

because I'm going to do anti-reflux procedure.

The old story of doing just one centimeter distally on the stomach,

you usually end up with an incomplete myotomy.

So, I always do a proper myotomy high up enough

and of course if it's a type 2, type 3, especially type 3 dysplasia,

dan sal ek op 10 cm soepel,

opvang ek wat ons sê op die manuputie en die X-ray's.

Daar is ons lichaam,

hier, vervormd, daar is ons.

Maar eerst, waarom isoleer jy al die esophage

as jy net die myotomie moet doen?

Daarvoor, sê jy,

ook nou, waarom?

Ek sê jy,

ek sê jy,

ek sê jy,

ek sê jy,

dit is korrekt

so hier is ons esophagus

hier is die fattie pad

die fundus van die stem

nou, die eerste stap wat ons gaan doen

is om die maal te doen

You can see the patient also has a rather large hiatus, so despite the fact that he has achalasia, we are going to close up his hiatus, and what I normally do is I close up the hiatus with a toupee, so that 50% of the space is occupied by the esophagus, and 50% space, and if you do it bigger than that, or you leave it like that, they herniate, and they get parasophageal hernias.

Right, so now we are going to start off by taking the fatty pad over there and over there.

Now again the position of the myotomy.

Traditionally the original helomyotomy was transthoracic

and the helomyotomy was on the left side to divide the sling fibers.

Lapeuskopieke, maak die meeste dienste op die rechterkant van die esophagus

en hulle divideer wat ons die klaspfibers noem.

Ek doe dit op die linkerkant, ek like die fibers hierover te divideer en ek gaan op die linkerkant,

dit is ons vagus nerve, die hierachter liggeweer is, die die vat vervang.

Ek gaan lateraal op die vagus nerve en ek gebruik dit ook vir traksie.

aswel. So wat we gaan doen is

start off by dividing

the fatty pad.

We go right down to the stomach.

You can see there is a little

layer of fat over here.

I'm just going to divide the

superficial layer with energy

and that's the only energy I'm going to use

on the esophagus, just to clean up

the muscle so that we can work

and see properly what we're doing.

You can see the liver of the patient is a bit big.

We're going to maybe

shift that liver retractor into a better

position over there right so we've got that over there now i'm gonna grab that one over there

and i actually grab the vagus as you can see i use that for traction right so it's just the fat

again dividing the fat we'll be pranky is better awesome right we're just going to clean the lens

at this stage just going to loosen that as well okay clean the lens just deflate the abdomen

Now the rest of the myotomy

I actually do with blunt dissection

I don't use any energy on the esophagus at all

You can just touch the mucosa of the stomach

Oh, that's fallen down

Let's just pick this up again

Excuse me, I'm here commenting

with a big surgeon from Milan

Dr. Roberto Russo,

wat verwonderd werd,

waarom jy

een toupee doen,

in plaas van een deur,

wat is die lege situasie?

Ja,

ek, ek just

die toupee verweer.

As ek sê, ek vond die deur nie.

Ek het, ek het voorsom

die deur doen, maar hulle

het een hoge insulens van reflux

naast.

Wat ook gebeur, as jy die deur doen,

dit hangt op die esophagus.

en dit is eindelijk die sofokus daar en ek weet dat ek geen dubbelgevende dubbelgevende studie nie het

om dit te vertaal, maar my eindelike dink was dat die patiënts eindelijk wat meer dysfasie het

en daarom het ek eindelijk, jy weet nie, geswitcheerd na die uh na die to paie, ok, daar is niets verantwoord met die doel,

ek prefere die to paie, ok, so is dit een persoonlijke keus, dit is een persoonlijke keus,

but i mean there are many surgeons that actually rather do it to pay than a door if it comes to the

achilles here right there we are good now we're going to start off with our myotomy

Ek het dit opnieuw vertaal, jy kan sê hoe sterk dit muskel is, dit is een typieke akalase, dit is soms meer dan een centimeter dik, esophagus.

In jouw ervaring, verantwoordelik die vat, daar is een risikofaktor vir squamous celles of geokarsinoma.

Ja.

Heb jy ooit in jouw ervaring die situasie gevond?

Ja, ek het patiënts met squamous cell carcinoma gehaald, en dit is behoorlijk interessant, die ene patiënt het een carcinoma gehaald, die van 20 cm langs 40 cm lang was,

een heel lang carcinoma, maar dit was superficieel, en we het een reseksie gehaald vir hom,

for that specific patient

was about

5, 7 years ago

and he actually

did well

but as I said

the carcinomas

in these cases look different from your

typical squamous cell carcinomas

they are usually more superficial

and well we know the incidence

of squamous cell carcinomas is 20 times

higher if you are

in achilles and then compared to your

normal population

so

they need to be followed up

but the problem is the carcinoma comes

15, 20 years later

and that's where the problem is

I just want to put this one in there for a bit

let's see, good

just putting my retractor

in there

you can see this is the vagus nerve

over there

and

you have to go up

until you start getting bleeding

once you get bleeding like this

then you know you're out of the lower esophageal sphincter that's your landmark because the sphincter

is actually very dry but once it starts bleeding you know you're in the esophagus proper

as you can see over here it's now starting to bleed right so there's our myotomy up there

now we're going to move down to the bottom part i always do the proximal myotomy first right

Right, the liver is quite a bit of a thing here.

And as you can see, you have minimal bleeding,

and the bleeding stops quite quickly,

because you rupture the vessels,

and they just curl up and clutter quickly.

This is quite an important technical point,

this, about concentrated bleeding.

Listen, does the patient have an asogastic tube?

Yes, he's got an asogastic tube.

ja, nou is die distale uitgang van die myotomie dat jy moet omhoog gaan

naar jou eerste groot transverse arterie, normaal gesê dat jy dit vind, want dit bloed,

maar jy kan dit eindelijk sê dat dit over daar kom, daar is die bussel, daar is die bussel, dit is die

bussel, ja, jy kan die bussel hieronder sê, hier is ons eerste groot bloedbussel, so jy moet

to go down to this vessel then you know you definitely in and on to the stomach and you

through and that's that's basically your landmark proximal five to seven centimeters distantly you have

to go down to this first transverse blood vessel it often bleeds a bit and again if it bleeds we

just pinch it we keep it for a while you'll see i don't use any energy on the esophagus whatsoever

ever the mikosa of the esophagus is quite strong it can probably take a little burn or two but if

you bring any energy near this gastric mikosa it might yeah there you can see it's bleeding a bit

it might look okay today but by tomorrow it's going to stuff and then you have problems

nothing we load down if yeah now that little bleeder we're just going to keep that for a while

and wait for it to stop bleeding.

That's all.

Don't burn it.

Don't be tempted to burn it.

You're just going to make a hole in that mucosa.

Maybe not today,

but for sure tomorrow.

Do you check with any other

hydrochromatic procedure

to check the mucosa or not?

No.

I don't use a scope or anything like that.

What I do is,

on day one, tomorrow morning,

the first thing that the patient gets

is a guess a barium swallow for few reasons first of all to document and make sure that you

have proper through flow and you didn't do a incomplete myotomy and secondly to check for any

leakage or bleed you know leakage or perforation and once that's done then the patient starts off

with with a clear fluid diet right that will stop just now we're just going to leave it not to

worry right now we're going to start off with a a total repair we're just going to have to do

something about this liver he's really got a big liver this guy okay thank you okay that's it he's

is hier, ek het een big floppy liver.

Ok.

Is dit typiek South African rugby liver?

You are, you are

right now busy with the World Cup, isn't it?

Yes.

Ja, we're doing quite well at the moment.

As usual.

Ja, no, for sure.

Ja, at the end of

August and beginning of September,

I was in

Bologna, and then

up to San Marino, and

Misano, at the Marco

simoncelli circuit for the motor gp and i spent a lovely week in misano i think you still that like

that for us just gonna keep this fat away and we had lovely weather there as well now say yet the

afro gray this is still stay peering me no says instrument op die grond groei right we're going

to close up the site is because it's very big and very wide oh let's just wash that lens i know

is there any association

between the achalasia

and the adusernia

or just in this case?

Well, 15%

of patients with achalasia

also have hiatus hernias.

So you must always check for the hiatus hernia

and you must be prepared to close it

if it's there.

But 15%.

What I'm using here is a

Ticron 1 on a

26mm needle. It's a

cardiovasculis uh cv suture all right i'm picking up the esophagus to present the

cruise taking a good solid bite at the bottom over there as well and mistake large bites it's muscle

otherwise it tears out very easily right and now we're going to not

oh let's just clean that lens again this is now the liver that's

kry, net so byg ek af,

stop, nou sê dankie,

right, let's go, closer,

going to put another stitch there,

I think two sutures will be necessary,

to close up the side,

this a bit,

see that, oh no,

ok, let's just clean that lens again,

and there's still a lot of suturing to be done,

maybe we should have done a door,

it would be easier,

ok, there we are,

let's just pick that up,

neem dit nou uit, en ek sal die lens klink, dit is die laatste dag, hier is ons, ek dink dit is gaan

ok, laat ek net snel die bloedbaf klink, daar, daar kan jy sê, dit is ongeveer 50, 50, 50,

top daar, net boven die

top suture, dit is

close diatis,

we must daar drop,

good, en dan gaan we

pik dit op soos dit, en

soos dit,

soos dit, ek kan dit soos dit,

daar is dit, nou gaan we

vir die bodem suture,

soos dit, snip die

stommel daar een beetje,

right here,

nou gaan we dit neem,

We have to clean that lens now again.

It will be over there.

Keep that one like that.

Just clean the lens again.

I'm concerning

other possibility

to do this

kind of treatment.

What is the best still

the surgery or comparing

to the poem?

The problem of the poem is that

our gastroenterologists are not so keen

to do it anymore.

They have had a few perforations

met myriastinitis.

Dat is die ene ding, en die andere ding is

dat hulle reflux.

Hulle moet op PPIs permanent wees, en we het

een paar probleme gehad,

en dan het ons ook

een paar verkeerde.

So hulle eindig met een LMI-automie

en die andere

probleem is dat

oor die PPI-gebruik

hulle nie heel blij is,

en dan moet ons vaak vir hulle terug

om een anti-reflux procedure

te doen met hulle.

But on the bedroom swallows that we do post-poem, the radiological picture is just never as good as when you do this procedure like this.

They're not nearly as open as you see with a LMR to me like this.

So, we did poems, but my gastroenterologist here at my hospital, they actually stopped doing it.

So they sent all the achalases up here.

Now you can see this suture that I'm putting here, I'm actually taking it around the vagus nerve.

Because the muscle of course is quite weak, and with the toupee, that can, I mean one cough it can tear out.

so ek moet een goeie stuk muskel neem, en as ek dit sê, inkluur die vagus nerve daar,

dan weet ek dat dit nie gaan vertaal nie, en dit gaan hierdie hou nie.

Ek gebruik hierdie 2 switche om die stem hier op die rechterkant te fixeer.

Natuurlijk is dit nie draad, is dit nie?

Ek bid jou verantwoordelik.

Nie, nie draad.

Nie draad, ek sê nie dat dit draad is.

vanwege by die tyd wat jy geslaag het, is al die bloeding gekleerd.

Ok, dit is vir ons.

So, laat ons net die lens weer verslaan.

Dit liwer het veel ...

dit is kraai.

Of ek weet nie, ek weet nie.

Kom nou daar.

Right, jy moet net instaan,

want ons moet dit liwer traktor schuif,

so ons kan net daar werk.

Net instaan, he?

Because that liver is flopping over at the back.

I'm also coming in at quite an angle.

What I'm doing now is I'm just rolling the esophagus over

and then I'm putting a suture over here

where it comes in contact with the cruci.

Liver is falling in.

And we'll just finish this one and then we'll...

By the way, on the external view, outside view,

Ek kon sê dat dit een soort bioniske hand is om iets nieuws te vertoon.

Ek het dit al jare nie gebruik.

Breng jy jy kamer op.

Laat jy dit daar.

Ek sal jy op die buitenkant sê.

Dit werkt met kompreserde lucht

en jy het hier een knop dat jy kan druk

en jy kan dit in enkele positie schuif.

Once you've clamped it there, you leave the button

and it freezes solid in that

position. It's made by

Braun and it's

a very good assistant.

It's not lazy.

It keeps the tension all the time

and it doesn't drop the liver.

Right. But it's

not as beautiful as an assistant.

Oh no, you will see my sisters.

Piero,

they are chosen.

They are chosen. That's it.

inside it again.

Right, we're closing there.

But you see, I used to have

male assistants until I met you, Piero.

And then you taught me the right way.

Now I don't have any

males in my theater.

Good, good choice.

Even

than it is.

Ja.

Ek denk hier die naald is gebeig.

Ja, ek krijg my ander naald.

Right, we're just going to get another needle.

That's it.

Right, we have to

just reposition this

again.

Right, clean the lens.

Did you sit om vir my weer oor op

die, ja,

nou sê, beter.

Oké, dan kan ons

my weer by kies oor, oopse,

oopse, oopse, oopse.

See, now this one, I

just use it like that, put it

into position, I clamp

my liver retractor, and I just leave

it, and it's solid.

Het is een geweldig instrument, het nie langsgeweer, het me alweer gehoor en het die job best goed doen.

Het blijft stil, het blijft heel stil, ja, heel stil nie, het my ook nie gekritiseer.

Jy kan sê dat die mykoos hier mooi uitbouw is.

By the way, if I do a toupee as an anti-reflux procedure, I use exactly the same technique.

It's just the closure of the hiatus is of course different.

Ein, Dr. Rousseau, which is close to me, is wondering,

how come you put so many stitches up there, considering there is a stenosis and fibrosis?

if you don't if they herniate you they end up with if you don't do it properly they get

parasophageal hernia and the thing is if you if you don't do your your to pay properly

they reflux they have to do a proper anti-reflux procedure and what's good about the to pay of

course i mean the door is an anterior partial fund application the to pay is a posterior

Oosteriër, partiaal van die aplikasie.

Basically, very much the same type of procedure

on either sides of the esophagus and stomach.

But you have to suture it properly,

otherwise it comes loose.

Because remember,

you're suturing muscle there,

and that's not very strong.

You call it impact.

Comptifope.

That's it.

Let's quickly just get that out of the way again.

I have two stitches on the right-hand side and usually three stitches on the left-hand side.

What also is a good thing about this is that you've got a good length of esophagus intra-abdominally

which of course is also important for the competency of your anti-reflux procedure.

Goed, en dit is ongeveer dit.

Daar kan jy sê hoe myotomie vervormd is, daar is ons toupee,

en jy kan sê dit gaan direct na die lichaam hier,

na ons eerste bloedwessel, wat ons daar demonstreerde, daar is dit.

Dit is jou landmaak vir jou distal mark van jou myotomie.

Ekselend, ok.

Okay, listen, die nasogastrik one is koming uit.

Is koming uit, yes.

Straight away.

Straight away, ja.

Yes, there we are.

We're just putting in a bit of local with magnesium.

And then we're just going to check our port sides for bleeding.

Nothing there.

Nothing running down this side.

And that concludes the procedure.

And by the way, it's much quicker than a poem.

If they do poems, it takes them an hour to two hours.

But Jurg is given up.

Alright, thank you very much

Thanks, congratulations

of course, from everybody

as a usual perfect technique

Listen, are you going to show

us other cases?

I have another eclasia

which we are going to do after this

case, we are just going to switch over

and then I am going to do another eclasia

This patient that we are

going to do next has got a very large

esophagus, we actually had to keep him

in hospital for a week

to clear his esophagus from all the food and debris that was in the esophagus.

So we're going to do a heller on him,

but this is often also the patient that you might at this stage

consider for a esophagus gastotomy

to make sure that they're able to swallow.

Of course the other option is a esophagectomy,

but that's a bit drastic I think.

If you can get away with a minor procedure,

I think that's probably the preferable thing.

But we're going to start off with a heller myotomy with him.

Alright, thanks very much,

from everybody. In how long

are we going to be ready?

In how long?

10 minutes? 10 minutes? 15?

Let's make 15. 15 minutes.

For a good cup of tea.

Okay. Yeah, good.

Thank you. Bye-bye.

Ciao.