Heide Van Der Walt

Right. Okay. 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, classical achalasia.

Yeah, so we've got our patient here. We're now going to tilt our table feet down

Stop and yeah, that's fine

Focus in on your bike, zoom in, right, okay, awesome, right now the placement of a male

patient, they've presented with quite a long standing knee, that's the rib edge over there,

He was evaded with manometry, as you can see, with a barium swallow as well, and on the endoscopy, on the rib edge of Ecclesia, and also on manometry, 14 cm from Ecclesia.

So we've got our pressure here. We're now going to tilt our table, feet down, but the top of the zinfesturnum.

So we're going to make a little incision there, and there's going to be incision just for a 8 mm port.

We're going to insufflate with a 5 mm stop.

Yeah, that's fine.

We can call the ambulance.

Good.

Now we're going to come a little closer.

Focus on your bike.

Stand on it.

Stand on your bike.

You have to stand there.

Alright, we're insufflating the abdomen to a pressure of 15 mm mercury.

Okay, stand up your back, zoom in.

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

Oh yeah, that's the Ziffy sternum over there, that's the rib edge over there, the rib edge over there.

Bloom black is down here, as you can see.

So our first port is going to be on the rib edge.

Good.

Now our next port is going to be for the camera, and that's about 15cm from the top of the

Zifi sternum, and that's going to be a 10mm port.

So we're going to make a little incision there, and that's going to be an incision just for

a 8mm port, but we're going to insufflate with a 5mm port at the beginning.

It's not normal for us to talk like this.

There's our camera going to go in now.

We're still holding out.

Right, we're insufflating the...

The outer side.

Okay.

Then our next port is going to be between the camera port and the insufflation port.

That'll be halfway, sort of a semi-lunar half-circle.

And that's going to be a 5mm port again.

Then we are going to put in a port at the top here, that's between the rib and the

xiffy sternum, and then halfway between those two slightly more lateral in the mid axillary

line would be another 5mm port, then we are going to swap the 5mm port here for an 8mm

8mm port and the reason why I use an 8mm port is that a 20mm or 26mm needle can easily go

through that.

Listen I'll knock off you.

You don't need bigger.

There's our camera going to go in now.

Right so this is our configuration.

Our 8mm port in the left hypochondrium, 10mm camera port in the midline 15cm down.

Then our next port is going to be between the camera port and the lip gauge over there.

We've got a 5mm port and a 7mm port in that area on the lateral side.

Right, now we're going to put in our instruments and elevate the liver.

There we are.

Then we're going to put in a port.

We're using an Olympus 3D system.

We're going to put in a port at the top here.

Spectacles that we have.

That's between the rib.

It's got a nice big floppy liver.

And the xiphy sternum.

We actually got it to use a little weight before the surgery.

to slightly more lateral despite his dysphagia in the mid axillary line he was quite overweight

would be another 5mm tall and he weighed 115 kilos then we're going to swap the 5mm port

here for an 8mm port and the reason why I use an 8mm port is that my instruments are

the storts or 26mm can easily go through that now we're going to you don't need bigger open

open up the pars flaccida or the lesser omentum right so this is our configuration eight millimeter

port in the left hypochondrium 10 millimeter camera port in the midline 15 centimeters down

a five millimeter between the ziffy and the rip cage over there we've got a five millimeter port

and a five millimeter port in that area on the lateral side right now we're going to put in our

He's not very tall, and he weighed 115 kilos.

A little bit fat.

I'm going to use the Olympus Thunderbeat.

This is getting to the right plane over there.

And my instruments are the Storz.

You can see the post here of Vegas coming through.

Now we're going to open up the Pars Flacida.

We're getting under that little layer there.

That's our layer.

That's where we have to go.

Right.

Just going to just open up there.

There you can see the post here of Vegas.

We're just going to open a third of it, get that down, right, there we are, good.

Right, now there's the caudate of the liver that's overlying our landmarks over there.

There we are, good.

Now we're going to open the aetis, this one, I'm going to have this.

Now we are dissecting down the cruciate ligament on the left side, there you can see the posterior

vagus coming through, divide the tissue over here, once we get in under that little layer

there, that's our layer, that's where we have to go, right, and loosen up the esophagus,

we'll do that a bit better, it's got quite a lot of fat around the esophagus, there you

You can see the posterior vagus nerve again.

Let's open up there a bit.

Lipoma there.

Get that down.

That's in there as well.

There's the nerve.

All right.

Good.

I'm going to take the short gas.

If you do, if I do a heller myotomy,

me, I usually do a toupee. If you do a door, you probably don't need to take a short gas

six, but I've found that if you don't take them, the door actually gives you quite a

bit of tension on the hiatus area, and it's sort of like misformed. I never get a good

position if I don't take down a short gas six. So we would routinely take a short gas

There's quite a lot of fat around the esophagus, that's fine, that's a lipoma there, there we go.

In the second place, yeah, comparing to Ayato Serenya.

What did your father say?

That one?

Yeah.

Yeah.

That one.

That one.

Yeah.

Yeah.

He has the nerve.

He'll try to get up.

Right.

Yeah.

And it's still a lot of pressure.

Good.

I'm going to take a short guess.

If you do...

If I do a Heller Myotomy, I usually do it to pay.

I usually do at least five millimeters proximal, usually much more, and two distally.

So I abolish the lower esophageal sphincter completely because I'm going to do an 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, then I go quite a bit higher on the esophagus, up to 10 centimeters sometimes, depending on what we see on the x-rays.

So there's our stomach, fundus, mucin. There we are.

But first, why do you isolate the esophagus when you only have to do the myotomy in front?

Piero, we have difficulty hearing your voice. I'm sorry.

60 lui dopo a una toupee that's correct our team is the length of the martini

because five millimeters proximal usually much more and two years

three meters so I abolish the lowest of your sweet to completely because I'm

going to do anti reflex and only for my dog seizure the old story of

of doing just one centimetre distally on the stomach,

you usually end up with an incomplete myotomy.

Right, so there we've got our esophagus.

That is the fatty pad.

I always do a proper myotomy on the stomach.

And of course, if it's the first step that we're going to do,

that's three, especially the myotomy,

you can see the patient also has a rather large hiatus.

So despite the fact that he has a chalasia,

we are going to close up his hiatus.

And what I normally do is I close the hiatus with a toupee,

So that 50% of the space is occupied by the esophagus and 50% of the 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're going to start off by taking the fatty pad.

I'm going to do a toupee over there and over there.

Now again, the position of the myotomy.

Traditionally, the original Heller myotomy was trans-thoracic and the Heller myotomy

was on the left side to divide the skin fibers.

Lapiscopically, most surgeons actually work on the right side of the esophagus and they

divide what we call the clasp fibers.

of the stomach. Now, I do it on the left-hand side. I like dividing these fibers here. I go to the left side. This is our vagus nerve actually lying over there. So, despite the fact that he has achalasia, I go lateral to the vagus nerve. And what I normally do is I actually use it with contraction as well. So, what we're going to do is to start off by dividing spaces 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're going to start off by taking a fatty pad over there.

You can see there's a little layer of fat area.

I'm just going to divide myotomy, the superficial layer, with energy.

Traditionally, the original yellow myotomy was transthoratic to transthoratic

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

Laparoscopically, most surgeons actually work on the right side of the esophagus,

and they divide what we call the clasp fibers.

I actually grab the vagus, as you can see.

I do it on the left-hand side.

I like dividing these fibers over here, and I go to the left side.

This is our vagus nerve actually lying over there.

This is the fat, again, encroaching the fat.

I go lateral to the vagus nerve.

I actually use it for traction as well.

So what we're going to do is to start off by dividing the fatty pad.

Okay, clean the lens.

Let's 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.

Why are you doing a toupee rather than a door?

What is the right situation?

Yeah, I just prefer the toupee.

As I said, I don't like the door.

I used to do the door, but they have quite a high incidence of reflux afterwards.

And what also happens, if you do the door, it hangs on the esophagus.

And it actually angulates the esophagus there.

And I know I've got no randomized double-blind study to prove it, but my initial thoughts were that these patients actually have a little bit more dysphagia.

And that's why I don't use any energy on the esophagus at all.

There's nothing wrong with it at all.

You can just touch the mucosa of the stomach.

Oh, that's falling out.

That is personal choice.

It's a personal choice, but I mean there are many surgeons that actually rather do a toupee

than a door if it comes to the achalasia.

Excuse me, I'm here commenting with a surgeon from Milan, Dr. Roberto Russo, which was wondering

What is the right situation?

and study to prove it but my my initial thoughts were that these patients actually have a little

bit more dysphagia and that's why i actually you know switched to the uh to the to pay okay

there's nothing wrong with the door i just prefer the to pay we just make

so a personal choice it's a personal choice but i mean there are many surgeons that actually

you rather do to pay than a door if it comes to the achilles here right there we are i'll retake

it again now we're going to start off with our myotomy ah you can see how tough this muscle is

it's a typical achilles it is sometimes more than a centimeter thick it is

in your experience

concerning the fact that there is a risk factor for squamous cells or gel carcinoma.

Have you ever found in your experience that kind of situation?

Yeah, I've actually had patients with squamous cell carcinomas

and it's quite interesting.

One patient had a carcinoma that was right from about 20 centimeters

right down to 40 centimeters.

meters. Very, very long carcinoma, but it was superficial. And we did a resection for

him. For that specific patient, this was about five, seven years ago. Yeah. And he actually

did well. But as I said, the carcinomas in these cases are different from your typical

squamous cell carcinomas they're usually more superficial and well we know the

incidence of a squamous cell carcinoma is sometimes higher sometimes more than a

centimeter thick in achalasia than compared to the 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 there for a bit, let's see, yeah.

Have you ever found

in your experience

that...

Yeah, I've actually had patients

with squamous cell carcinomas

and it's quite interesting. The one patient

had a carcinoma that

was right from the vagus nerve

20 centimeters

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

softness. We did a resection for him

So you can see a minimal bleeding, and the bleeding stops quite quickly, but the problem is that the carcinoma comes 15, 20 years later, the vessels, and that's where the problem is.

And they just curl up, and I just want to put this one in the way for a bit.

Quite an important technical point, this.

Good, yeah.

Concerning the bleeding, does the patient have a nasogastric tube?

Yes, he's got a nasogastric tube, yeah.

You can see this is the vagus nerve, the distal extent of the myotomy is that you should go

up, down, 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 your esophagus is proper.

As you can see over here, it's now starting to bleed.

Alright, so there's our myotomy up there.

now we're going to move down to the bottom part always do the proximal

myotomy first right the liver is quite a bit of a thing here and as you can see

a minimal bleeding and the bleeding stops quite quickly you can see the

vessel over here is our first blood vessel and they just curl up and

So you have to go down to this vessel, then you know you are definitely in and out to

the stomach and you feel that's basically your landmark.

Proximal 5 to 7 cm is the density, you have to go down to this first transverse blood

vessel.

Now, the distal extent of the myotomy, and again if it bleeds, you just pinch it, keep

it for a while.

your first I don't use any energy on the esophagus whatsoever the mucosa of the

esophagus is quite strong it can probably take a little bit because it

bleeds but if you bring any energy you can see this is a ghastic mucosa it might

be either you can see it's bleeding a bit it might look okay today but by

tomorrow it's gonna stuff and then you have problems there's the vessel so

That's a muscle.

You can see the vessel over here.

There's our first large blood vessel.

So you have to go down to this vessel.

Then you know you're definitely onto the stomach.

That's basically your landmark.

Approximately 5 to 7 centimeters distally.

You have to go down to this first transverse blood vessel.

Don't burn it.

Don't be tempted to burn it.

you're just going to make a hole in that mucosa and again if it bleeds maybe not

today for sure too well you'll see I don't use any any other the softness is

quite sure it can probably take a little but if you know any energy I don't use a

scope or anything I can go sir my what I do is on day one tomorrow morning might

look okay to the thing that the question is I guess a barrier swallowing problems

problems for a few reasons. First of all, to document and make sure that you have proper

through flow and you didn't do an 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 a clear fluid diet. Right. That will stop just now. We're just going to leave that.

not to worry right now we're going to start off with a thing yeah and wait for

it to stop being pencil okay don't burn it don't be tempted to burn it you're

just going to make a hole in that micosa maybe not today floppy liver check with

with any hydrotumatic procedure.

Is it typical South African rugby liver?

No.

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

You are.

What I do is, on day one, tomorrow morning,

the first thing that the patient gets is a barium swallow.

As usual.

For a few reasons.

First of all, to document and make sure that you have proper through flow

and you didn't do an incomplete myotomy.

me and secondly to check for any leakage or bleed you know at the end of uh august and beginning to

september once that's done i was in the patient starts off with bologna and then up to some

marino diet and misano at the marco simoncelli circle stop just now for the moto gb not to worry

and right now we have to start off with a misano pair we're just going to have to do something

about this liver he's really got a big liver this guy he's gonna keep this okay and we had lovely

weather there as well i'll say yeah that's it he's got a big floppy let's tape it in here okay

right we're going to close up the scientists because it's a typical south african

Oh, let's just wash that lens.

You are a great job.

Please, we didn't work up, isn't it?

Is there any association between the achalasia as usual or just in this case?

No, for sure.

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.

Yeah, at the end of August and beginning of September, I was in Bologna, and then up to San Marino.

What I'm using here is a Ticron 1 on a 26mm needle.

It's a cardiovascular, and I spent a lovely week in Misano.

I'm picking up the esophagus to present the cruz.

Good solid bite at the bottom, and we had lovely weather there as well.

as well as I still say mistake large bites it's muscle says instrument always

tears out very easy right we're going to close up the site is because it's very

big and very wide oh let's just watch fit right and now we're going to not

lens I know is there any association between the Achilles ya ya ya ya ya ya

oh well 15% of patients with Achilles and now the liver have it is only a

crying and it's a big yeah so you must always check for the itis area you must

be prepared to close it you know if it's there but one five fifteen percent what

It's a cardiovascular CV suture.

All right.

I'm picking up the esophagus to present the cruz,

taking a good solid bite at the bottom.

You need to put another stitch there.

I think two sutures will be necessary as well to close up the side just a bit.

You must take large bites.

It's muscle.

Otherwise, it tears out very easily.

Oh, no.

Now, okay, let's just clean that lens again.

And now we're going to knot.

And there's still a lot of suturing to be done.

Maybe we should have done a door, it'd be easier.

Okay.

Let's just clean that lens again.

This is now the liver that's crying.

Need to pick it off.

Pick that up.

Stop.

Over there.

You can see the aorta lying over there.

I think two sutures will be necessary

to close up the side

just 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, oh, that's ok

let me just finish here, take it out

ok

there we are

clean the lens

over there. You can see the water lying over there. There we are. I think that's going

to be okay. Let me just quickly clean up the bloodbath. Right, there we can see it's about

here. Take that one out. Okay. I'll clean the lens. That's last. There we are. I think

that's going to be okay. Let me just quickly clean up the bloodbath. We're going to fix the stomach

to the cruciate top there, just above the top suture. Let's close the hiatus. Right there we

can see it's about a 50-50-50. That's the vagus nerve. Oh, we missed that drop. Okay, hold that

one like that. Good. Now we're going to pick this one up like that and just turn it like that.

I can keep it like that. There we are. Now we're going to put through our bottom suture.

I'll snip the stomach there a little bit. We're going to fix the stomach to the cruciate

top there. Just above the top suture. It's closed diatis. Optima. Oh, we missed that drop.

Concrete down. Good. Then we're going to pick this one up like that and just turn it like that.

I think you can keep it like that there we are now we're going to see your bottom feature

right here stomach a little bit oh good now we're going to take the we have to clean that lens now

again it's going to be over there right and keep that one like that just clean the lens again

The problem with the poem is that our gastroenterologists are not so keen to do it anymore.

They've had a few perforations with mediastinitis, that's one thing, and the other thing is they

reflux.

they have to be on PPIs permanently and we've actually had a few foams that we had to come

and then also we've had quite a few failures so they end up with a LMR to me anyways and

the other problem is that because of the PPI use they're not really happy about that and

then often we have to bring them back to do an anti-reflux procedure with them.

But on the barium 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 say they are.

Concerning other possibility to do this kind of treatment, and what is the basis to the surgery for comparing it to the poem?

They've had a few perforations with the gastroenterologists.

I'm actually taking it down the vagus nerve.

They have to be on PPI for a minute, one week, and with a two-pay, that can tear out quite a few fingers, so they end up with a good piece of muscle, and the other problem is that because of the PPI use, they're not really happy about that, and often we have to bring them back to do an anti-reflux procedure with them.

But I just use two swallows that we do post to fixate the stomach here on the right side.

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 hella myotomy like this.

So, we did poems, but my gastroenterologists 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 out of the vagus nerve.

Because the muscle, of course, is quite weak.

No drainage.

Of course, we have to shift this liver tract so we can just work over there.

Just stay inside, eh?

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 this over.

Of course.

No drainage.

I'm putting a suture over here.

I beg your pardon?

No drainage.

It comes in contact.

No drain.

No, I don't need to drain.

Usually by the time that you're finished, all this bleeding is cleared up.

back i'm also coming in um by the way on the external view outside view i could see it looks

like there is a sort of but bionic i'm doing now i'm just running this over something new putting

a suture over here i've been using this for years um where it comes in contact with your camera

yeah i'll just show you on the outside it it works with compressed air

and you've got a button that you can push here and you can just shift it in any position once

you've clamped it there you leave the button and it freezes solid in that position uh it's made by

brawn and it's uh it's a it's a very good assistant it's not lazy it keeps the tension

all the time and it doesn't drop the liver so right but this is not as beautiful as an assistant

Oh, no, you will see my sisters, Piero, they are chosen, they are chosen, livers falling

in.

I will just finish this one and then we'll...

That's it, inside again.

All right, we're closing there.

But you see, I used to have male assistants until I met you, Piero, and then you

talked to me the right way.

And I, by the way, on the external field outside you, I could see it looks like there

is a sort of bionic hand to kiss the liver, something new, good choice between you and

I've been using this for years.

Just put your camera.

I think your needle is bent.

I'll just show you on the outside.

It works with compressed air.

Right, we have to reposition this.

And you can just shift it in any position.

Once you've clamped it there, you leave the button and it freezes solid in that position.

that's it inside again all right we're closing there see now this one you see i used to have

male assistants until i met you in the position and then you taught me the right way clamped my

liver retracted and i just leave it and it's now i don't have any males in my theater

lovely instruments good choice good choice never lazy always

He always listens to me, and does the job quite well.

And keeps quiet.

He keeps very quiet.

Very quiet.

Never criticizes me either.

Just reposition this.

You can see the mucosa bulging out beautifully over here.

Right, clean the lens.

Thank you.

DJ, sit on for me over here.

Deep.

Yeah, that's right.

Better.

I'm careful to not stick a hole into the esophagus over there.

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.

Lovely instrument.

Never Lazy always listens to me and does the job quite well.

This, by the way, if I do it to pay, it keeps very quiet as an anti-reflux procedure.

I use exactly the same technique.

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

Dr. Rousseau, which is close to me, is wondering how come you put so many stitches up there

consider is a stenosis and fibrosis if you don't if I herniate you they end up

with if you don't do it properly they get parasophageal hernia and the

thing is if you don't you're not you're to play properly so for the reflex they

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

Of course, I mean, the door is an anterior partial fundoplication.

The toupee is a posterior partial fundoplication.

It's basically very much the same type of procedure on either side of the...

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

But you have to suture it properly.

Otherwise, the closure of the hiatus is, of course, different.

Because remember with a, you're suturing muscle there, and that's not very strong.

Dr. Rousseau, which is close to me, is wondering how come so many stitches up there,

considering there is a stenosis and fibrosis.

If you don't, they herniate.

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

and the thing is if you don't do your your to pay properly the reflux they

pay of course I mean the door is an anterior partial underplication to pay

is opposed to it as quickly just social foundation 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 remember with it with it you

suturing muscle there and that's not very strong and I put two stitches on

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

the right hand side and usually see switches on the left hand side what also is a good thing

about this is that you've got a good length of esophagus inter-abdominally which of course is

also important for the competency of the anti-reflux procedure let's quickly just

get it out of the way again good and that's basically it well you can see

There's your myotomy exposed, there's your toupee, and I put two stitches on the left

hand side and three on the right hand side.

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, interabdominally,

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

Just putting in a bit of local with magnesium, and then we're just going to check our port

sites 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 has given up good.

And that's basically it.

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're going to do after this case.

We're just going to switch over, and then I'm going to do another eclasia.

This patient that we're 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 the food

gastric when he's coming out?

He's coming out, yes.

Straight away.

But this is often also the patient that you might at this stage consider

putting in a local gastrointestinal magnesium to make sure that they're

able to swallow.

Of course, the other option is esophageal ischemia, 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 the other side.

All right.

Thanks very much, Ryan.

from everybody in how long and by the way it's much quicker than how long 10 minutes

takes 10 minutes 15 let's make 15 15 minutes for a good cup of tea okay yeah good thank you

thanks congratulations of course from everybody as a usual perfect technique listen where are you

going to show us other cases i'm going to i have another ecclesia which we're going to do after

this case we're just going to switch over and then I'm going to do another

now they crazy this patient is that we're 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 you're

going to do a header on him but this is often also the patient that you might at

the stage consider for a sufferer gastotomy to make sure that they be

be able to swallow. Of course, the other option is 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 the LMI-automy with him.

All right. Thanks very much, Ayn, 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.