H. VAN DER WALT

Right, our next patient that we have is a patient with a total intra-thoracic stomach.

I see the redo that we had has been replaced with this patient.

So this patient has had a complete intra-thoracic stomach

and basically presented with chest pain, dyspnea

and the symptoms of shortness of breath due to this intra-thoracic stomach.

so we can probably go on it's quite interesting to see inside what it looks like right we can go to

the internal picture can you see that we don't see anything now yes now we back okay okay fine now

there you can see the colon there is the liver but no stomach right the reason for that is that the

die hulm is in die hulm.

So, laat ons die hulm pakke,

nog nie hulm,

so daar is nie hulm.

Wat ek gaan probeer te doen, is om

jy die techniek te show wat ons gebruik

om die intra thoracische hulm te manageer

wat jy bestel,

wat jy bestel,

nie te hard,

nie te hard,

nie te hard,

nie te hard,

nie te hard,

Right, okay.

Let's have a look.

Here you can see the

bottom part of the stomach,

the pylorus, right up here.

Look at the gallbladders also here in the

under the left lobe of the liver.

And the porta hepatis

is shifted right over

to this side.

So honestly very careful, there is the caudate lobe

of the liver. Right, now when we

do the intertherasic stomach,

what I'm going to do is to use

the harmonica over here it's a bit slow compared to the hook and also a bit expensive compared to the

hook but with the interferesic stomachs it helps quite a bit otherwise it can be a bit bloody right

nou prof van der Waald, kan jy my heer?

Right, this is

now the intra thoracic stomach,

so what I've done now is to

identify the crust on the

left hand side,

and this of course is the crust on the right hand side.

So all I've done is to grab

the sac, bring it into the abdomen, and I'm just

loosening the sac now. And what I'm

going to do is go all along the sac,

and this is the technique. You'll

see I don't pull this, just

grasp it and pull it towards yourself.

jy sê ek probeer nie om die stemme te plaas te laag en dit te verduur, en jy sê nou waarom.

So wat ek doen is net die eide van die zak identifieer en daarna langslaan.

Hier sê jy die kruis op die rechterkant. Ek verduur nie, ek verduur net die zak.

Dit is heel laag, he? Ja, vir zeker. Dit is een groot.

one. You have to squeeze that a bit.

Geef my an a grasp

vir hierdie grasp. Vat nie.

Back up sê. Altijd vir

hierdie type van goed.

Let's just get that one in there.

Squeeze it with your fingers.

Put it. Squeeze it.

Grasp it. That's it.

Good. Right.

Here we're basically taking the sack still

and just moving the sack out

and going along

just identifying the edge

of the diaphragm. I'm not trying

to pull the stomach back i'm not trying to reduce it the trick is to keep the stomach inside the chest

because once you bring it out then it's quite difficult to actually get to

the cruise because it's such a mess and everything tries to go in there as well

and if you try and pull it out it just pulls back again you never get it out

there we are how long is the history for this patient oh it's been for me for quite quite many years

The patient didn't have much reflux.

The symptoms of the patient

is more mechanical

due to the stomach that he had in the chest.

He had nocturnal regurgitation,

but the big problem was not actually heartburn,

it was regurgitation, volume reflux,

and the effects,

that, you know, shortness of breath and so on.

That's it.

Right, now we're going to take that one there.

You see the minute you bring it back.

Okay, so we've loosened this now, I'm just going to put that back a bit,

because if you pull it out, you can see the minute you pull it out, you can't see what you're doing.

Now that's a very good point.

A little bit lower, yeah, you must put it back into the chest.

Going down a bit lower, right, I want you to just pull that over to the lateral side like that.

Good, that's perfect, that's perfect.

Right, open that up over there, see how far we can go down.

daar is een ander stuk daar, dit is wat ons wil vertaal en nou wat ek doen is

eindelijk nou terugkom en vertaal my korte gastriks wat ek vir hier kan vandaan

, net die boek vir jou en jy sal sê waarom in een minuut, ons besef die

metikulose van jou actie, ja, dank jy, ek sal net bewaar, so heel belangrijk hier is

om eindelijk die lichaam af te vertaal, daar is ons, die kleine bugger, oh daar is het,

Ek sal hier die kind na hier.

Ek weet nie.

Ok.

Ek sê fyn.

Ek sê.

Ok, ek sê jy het.

Ek sê hier is sy.

Ek sê.

Ek sê.

Ek sê.

So dit is dit, wat dit is.

Ek sê die top van die spleen is ook dit.

Dit is dit, ek dink ons het dit daar.

Daar is ons, ons vind dit nou.

Ek wil net oorlaat dit daar so dat ons dit stem uit kan neem.

Daar het dit.

Daar is die kleine bugger.

Daar is ons, daar sê ons dit.

Ek sê dit, vanwege ons so hard te draag,

het dit terug draag.

Daar het ons, ek sê dit.

Dit is dit.

Well, that's the whole thing about a bleeder, eh?

You just got to keep opening until you find it.

Yes.

Good. That looks better.

Just make sure.

Okay, I think it's time to clean the lens now,

but I think we've got that little bleeder.

Right, clean the lens.

You see, I think it's because we're pulling so hard

when we divided that blood vessel

that pulled back right into the bed posterior to the stomach.

And you just have to open it up until you get there.

Right, let's go and have a look.

ja, dit kyk best lekker en duur, goed goed, nou kan ons na die bloedbouw continue,

goed, goed, jy kan sê dat ons deurgevorming het gedeelde het, die vandes van die lichaam is

uit die boek gegaan en nou gaan ek daar in en jy kan sê dat die lichaam nog steeds in die

deur is, ja, oké, nou wat ek gaan doen, is ek gaan die lichaam oordelen

en ek sal langs die saak soos dit.

En jy plaas die hele stem met die saak,

alles sal nou uitkom.

Jy sal sê.

Die hele ding is om die saak op die eide te vlie.

Anders, as jy die stem plaas, sal dit oorweer vlie.

Ok, ons sal waarschijnlijk die straan daar oorweer sê.

Ok, hier kom die,

soos jy sê.

Ok.

Daar is ons.

Now the sac is out

and there is the stomach and now I'm pulling the stomach

back. There comes the stomach

into the abdomen.

Right, and here is the sac.

Yes, Prof, how often

do you see volvulus? So you do have to

do an emergency operation

for strangulation or so?

That's actually quite

seldom in primary cases.

But I've seen it in a few patients

all that, where we've done

redo surgery. That have

had previous surgery

die persofagelernie ontwikkel, en dan kom in met pijn, stangulering,

hulle uiteindelik in die cardio-thoracie ICU, en die medis sê daar,

doen test en kyk sy hart vir een dag, voordat hulle realiseer,

nou, die patiënt is gaan dood, en uiteindelik, as hulle start dood,

dan het hulle die doodsaak genoem.

Ja.

Hul is vaak misdiagnoseer as cardio-probleme en hulle uiteindelik

met die medis sê, wat een groot probleem is.

It's a delay of course.

Yeah, the delay makes it

and then often

they only make the diagnosis once

the patient has gangrene perforates

and they see it on the x-ray

when they do the x-ray for the

dyspnea that the patient's developed due to

his ARDS that he's getting.

There you can see the aorta.

There it is.

You can see that

massive cavity over there

where the renea was.

It's an enormous gap.

Ja, prof, sorry, we miss the connection initially, but as the patient had an endoscopy

and could see well that the cardiac was in the right position?

Ja, when you did the endoscopy, the whole stomach was inside the chest.

You could actually, and of course when you do a bit of insufflation,

then the stomach deploys back into the abdomen.

But there you can basically now see, that's our esophagus.

We are just going to make sure that it is loose on that side as well.

Hold that for me like that.

And I usually use blunt dissection here.

Just to strip off all this tissue.

But one must be very careful.

Sometimes this esophagus is very friable.

It can actually tear very easily.

So very gently we just tease it off there.

There as well.

That's it.

Good.

There we go.

There we go.

That's the vagus plexus over there.

Anterior vagus nerve ook daar, jy kan dit sê?

Heel goed, dit is die anterior vagus nerve, ja.

Goed, ek dink ons het genoeg esophagus daarna.

Ons ons dit oplos, ek dink ons sal ok.

Goed, so nou, die probleem is met dit.

Nou gaan we na die kontroversie van die meshe.

Ek haat meshe.

Die reden waarom ek meshe haat,

is omdat al die complikaatsies van meshe vaak met my aansluit

en ek het dit te fixeer.

So I've seen some horrible complications of mesh with erosions, patients ending up with esophago gastrectomies,

patients ending up with fistula abscesses, ending up with mediastinitis because of erosions of mesh bleeding.

It's been a, I'll tell you, I've seen so many problems with mesh that I try and stay away from the mesh as far as I can.

How long after the position of the mesh you have this kind of problems, prof?

Some of them actually the sepsis that you see with meshes often come two three months down the line

and often they come one two years down the line. I've had one patient with a mesh that had the mesh

for three four years came back had a big erosion into the esophagus. This was actually a number of

years ago. We've lost okay you're back now. Okay I've just all that like that. I've had patients

Ek het patiënts gehoor wat mes in die gorteks het, wat jy van die esophagus kan sê.

Nou, ongeveer 10 jaar geleden, lang voordat notes, het ek een patiënt gehoor met

een erode gorteks mes, dual mes, in die esophagus.

En endoskopieks, het ek die mes uitgeleid, het ek die suture gehaad wat dit in plaas gehaad het en het dit vermoord.

So, lang voordat die mense dink van nots, was ek daardag dit doen.

So, en sinds dan, het ek echt veel complikaatsies van mes gehaad.

Die, die, die, die, die, die andere complikaatsie wat heel slecht is, is as die patiënts

develop fibrosis where something is bleeding yeah let's have a look there okay fine on a taste

you get some of these patients they start developing fibrosis of the mesh

after it's been placed they get progressive fibrosis and then you have to go back

to loosen the mesh and to take it out because they get complete dysphagia and esophageal

obstruction and when you get inside here there is so much fibrosis from that mesh you just can't get

into the into the abdomen but the problem is sometimes if the diaphragm is very weak and thin

as this one is flimsy you sometimes have to resort to mesh but we'll see if that's necessary

because i have a technique that i use and i've been using this for quite a few years now trying

to stay away from mesh with good results and i'll show you now what i do now the next thing cassius yes

when you go back is an open surgery or again a video laparoscopic a laparoscopic laparoscopic

if you don't get in with a laparoscope you're not going to get in with open surgery

really i uh these patients often you have to cut out a piece of the diaphragm

the mesh is eroded, the esophagus

is just fibrosis

and you end up doing an esophago-gestectomy

sometimes you have to use

a combined approach through the abdomen

and then also with thoracotomy

to actually, I'm just relaxing

this liver attractor a bit

to put less

tension on the diaphragm

again the anterior suture

then you have to use a combined approach

through the chest and through the abdomen

to be able to

jy weet, om opnieuw te vertaal, um die esophagus in die lichaam as jy een reseksie het

van die hele mes, ek sal sê mesoma sê, jy kan dit eigens noem, want dit word een fibrotise tumor

wat jy net nie kan vertaal, uh, ja, ja, sê so flimsy die diafragma, sê hulle die suture

is all nicely yeah no they don't we'll we'll we'll watch we'll see this very carefully

i usually see you know if i see that the um this fasciculation and the

the diaphragm pulls out and there's no strength in us you know then you have to put in a mesh

so although i say i i you know i try and stay away from measures sometimes there is an indication

en dan moet jy dit uitgewees, natuurlijk.

Jy kan nie net sê, ok, ek gebruik nie mesjes,

nie ooit.

Ja, ek kan nie verblik met dit.

Dit, ja,

soms moet jy dit gewoon uitgewees.

Ek moet sê, dit dieframe is

verweer verweer flumsie, het wek.

Het thin,

dit het nie te slem gehoor.

Alho, laat ons

kijk op die laterale kant, ja, jy sê,

dit is die wek part van die dieframe daar ook.

Dit is waar dit gegewees.

Dit is die grootste probleem,

so wat ek doen is ek maak in een laterale stik en in dit geval sal ek waarschijnlijk in 2 maak,

so ek wil daar wat substans grap nie, dit is in die big bites, erg belangrijk, anders dit ding

net kruis en probeer om een beetje van die peritonele laai daar ook vir sterkte te kry,

dit is die augmenteering van die kruis, jy sal sê wat ek nou doe, dit is alhoewel dit soos

like a figure eight stich it actually folds the one cruise over the other one or one part of the

cruise over the other one you'll see now what it does and you mustn't turn it of course make it

too tight because if you make it too tight kom nader it pick you know it's it's in actual fact the

ischemic stitch and that's not what you want yeah because the muscle will suffer yeah for sure

look what it does yeah look what this stitch does it puts it over and across each other yes

Yes, you can see clearly.

Yeah.

And it rolls the one part of the cruci in behind there.

Can you see?

Yes.

So it sort of gives you a double layer.

It took me quite a while to work this one out.

How many of these lateral stitches do you put on, prof?

Usually, if I can, just one.

But in this patient, obviously I'm going to have to put in two.

Maybe three.

As much as is needed.

result that you get with this.

By the way, I wanted to ask you, you know

that Bert Meijer passed away

last year. Oh, I'm sorry about

that. I didn't know.

Yeah, I had severe

emphysema and

succumbed to lung

complications. The head of the

department now in Johannesburg is

Martin Veller.

oh en uh ja en martin smith is regering barraguana al right yes ek sê dat jy hulle al weet al

die hoofd van die departement van praetoria op dit moment is hennie becker al right

sê hallo van my van pierre oma bertie as jy hulle sê eh oh wel ek het eindelijk

my hart

in South Africa

which was the best

country to live the heart.

Was the best country to live the heart.

For sure. It's a nice country

to play soccer in as well.

If you're Spanish.

Well, let's leave it.

About our performance last year.

That's right. Yeah, it was a lovely

event for us. I actually went

to the final. Oh, very good.

Right, so you can see

there it's closed up in front. Now we've

reduced the zaitis about half

the size. Let's have a look.

Looks good? Yes,

excellent. Just want to clean

up there a bit.

As my sier terug sit as ek om daar sit word,

dan moet ek sy plek toe gaan.

What I always routinely do with the intrathoracic

stomachs, is I put a drain

inside that cavity.

Because if you don't put a drain inside that cavity,

kom na harder,

die negatieve druk van die interthoracieke druk,

in al die bloed en seroma in daar,

en hulle kan soms eindig met groot collecties

in die kist van bloed en seroma en so op.

En dan moet jy later terug en die draai.

As ek terug terug draai,

ek sal normaal gesê door die lewe thorax met die skoop

en ek sal die saak open en in die kist draai.

Maar dit is kambersom.

Sure, but the drain you leave

into the abdomen, you put straight

a chest drain.

No, in the abdomen, and I put it

through the diaphragm.

Through the itis over here.

Right.

Hoe naarder?

Hoe sê hy? 19 bleek drain.

Met die 54, so.

Kreeg hy van die gehaal.

What happens here of course is

I

repair the diaphragm

in three areas.

anterior, lateraal en posteraal. Dit is een drie-pointerdeel en ek is hier kom om dit

die Mercedes repair te noem. Waarom dat? Want dit soelt soeke die badge? Dit soeke die badge van die Mercedes.

Wel, dit is soeke die Nissan repair, jy weet. Nissan is ook een auto.

Ek het net een suture gebruik soos hierdie, maar ek sal van die suture raak, so ek sal

het na een ander gebruik gaan. Ek gebruik normaalgevend net een suture wat ek hierdie operasies doe.

You can see how nicely you can slide the suture

and close it up.

I must say that the lateral stitch really helps.

It helps a lot.

Otherwise you just have too much tension.

There's no ways you can close this hiatus.

Right, let's have a look and see what that looks like.

Yeah, it still needs a suture, eh?

Is the patient going to be

extubated straight away on the table?

Who's going to go to ICU?

I beg your pardon?

Is the patient going to be extubated on the table?

ekstubeer dit op die tafel,

en dit gaat terug in die wad.

Hulle het normaal gesê dat hulle betere lankkapasiteit het

na die operasie, dan vanaan wanneer hulle in kwam.

Omdat jy minstens

een liter of twee toegeef

vir hulle vitale kapasiteit,

door die lank uit die borst te neem.

Professor van der Waalte,

Just now is close to me

Professor Spallazzini

On his behalf, I say hello

I congratulate you with all your procedures

And we know that

is going to be another one after

this. And they say

thanks very much from Professor Palazzini

who stands by me just now.

Can you hear me, Prof?

Hello, Prof. Van der Waald?

Prof, as jy ons kan heer,

as we've lost the audio signal so we can't hear you too can still see your procedure that you're

doing the nis now but we can't hear you at all unfortunately can you do anything over there

to make us listen to you again because we can't hear at all can see well but can't hear

Oké, kan jy me nu heer?

Ja, ja, kan jy me nu heer?

Oké, daar is ons, we hebben verlaat.

Goed, jy sal sê dat wat ek gesê het,

jy sal sê wat ek nou gesê het,

is om die, daar is waar ek

die korte gastriks verloos,

en wat ek gesê het, is dat ek

teruggegaan is, teruggegaan, totdat ek

daar is waar die lichaam opgegaan is,

en ek het die vat verlaat,

so dat uiteindelik ek

die goeie fundus daar het,

en nie die vat op die sêde ook.

Right, the oesophagus really looks like something that the cats have been eating, but we've got a good overlap there.

Yes, very good. We have followed very nicely your operation, we only lost the audio. By the way, Professor Palazzini was standing by me, he says thanks very much, he says hello to you.

ek het gehoord dat jy sê ek nee oké jy het me gehoord dank u ek het nog steeds gehoord dat jy sê dat ja nou

we het die audio al die tijd op die kant ja in feite het ons dat geapprecieerd het wat ons verloor het

jy van die kant kon jy nie hoor jy maar nou is dit perfect alles weer terug naar normaal goed

en nou moet ek vis so ek hou dit so dat nou gaan we vis hier we het

We caught a fish. This is the fishing maneuver. Yes. It's a De Waal river.

Now although these patients, often they don't have reflux, this patient had severe reflux,

but often these enterothoracic patients don't complain about reflux. Now, I still do

innocent for those patients because you need something to anchor the stomach down here

to keep the stomach and to keep

the esophagus down. If you just do

a simple repair, like the old

Allison repair where you just tie it down,

then of course you've got a very, well

50% failure rate.

Even as it is, the failure

rate is three times higher than with your normal

repairs. So what I

do with these patients in follow-up,

I follow them three months down the line,

six months down the line, one year down the line.

If they're fine, I sit back and I relax.

Very good.

No dysfage at all.

Well, often they don't have dysphagia, well, their dysphagia rate is very much the same as the normal patients.

But sometimes again, surprisingly little dysphagia, if you see how much work is being done here.

Look in the other.

Okay, it looks like we need to put in a little extra stitch there, we'll see now.

The other thing is these, because these diaphragms are so thin, you actually have to close them up quite tightly.

If you leave them just a little

bit loose, they tend to re-herniate

very, very easily.

So it's important to actually tie them up a bit

tighter than you would normally tie up

your nissen.

It won't

compromise the blood supply?

I don't think so. I hope so.

It doesn't look like it.

Because we do

a fair amount of this.

We had one week the other day that we did five

of these interferasics in one week.

Now then you don't sleep very well

alwys.

It's really amazing.

It's amazing the figures that you gave to us.

Yeah.

Right.

That city of South Africa is fantastic.

Yeah.

Well that's one thing, I mean you work here

yourself. You know the volumes of

work here is enormous.

Is it still the same?

It's still the same. It's worse.

Because all our doctors have gone to

Australia, New Zealand,

you know, Canada.

Ja, ek...

Gelukkig, hulle spreek nie.

Ek weet oor...

En ook die Italiërs is teruggegaan in Italië.

Ja, maar dit is myself.

Ja.

Maar ek mis dit slecht, in ieder geval.

Ja.

Daar gaan we.

All right.

Dit ziet een beetje sterk uit, he?

Niet sterk, maar ek meen,

as far as tension is geconcerned.

Maar ek denk,

as we misschien

dat een beetje verlaat,

dat we dat een beetje verlaat,

en net die tension daar verlaat,

Ek moet nie jou handen uitsteken.

Ek moet net nog eens knoop hierin sêt.

Kom dit na die reiter.

Just an extra one for luck.

Right.

There wasn't much tension on that.

Ja, that's it.

It's a bit tight.

You know, there, kom na die reiter.

But rather a bit tight.

But rather the patient have a bit dysphagia.

You see, I also have a error.

If you want to make a error,

rather make it a little bit too tight.

dit is veel makkelijker om een stik na 1 week te neem, dan dit is om een redoe operasie te doen 1 jaar langs die lijn

en dit is, so as jy een verandering wil maak, ja, as jy een verandering wil maak, maak dit een beetje te sterk

, jy sal nie oorspring wees, ok, jy sal oorspring wees as jy dit nie te sterk maak genoeg, dit is

een heel goeie punt prof, een heel goeie punt, een goeie trick, ja, nou, ok, is dit een suksioendrain prof

prof. Yes, I put in a suction drain. What I do when I put in a drain, I take my grasper, put it out

through this port. Just take that one over there like that. Then I pull out this port and grab my drain

with my grasper and pull it back into the abdomen. Right. Now I'm just going to suture this in position.

hier is sylikoon draai, ek wil dit op die buitenkant soos ek het die tendensie het

om alweer uit te draai, en soos jy weet is dit nie so makkig om terug te draai en dit terug te draai, ja, ons het

een externe uur nu, ek kan sê dat jy dit fixeer, ja, soos die patiënt dit nie draai,

ja, normaal gesê het ek dit lewe in vir 24 uur of so, nou wat ons doen is ons neem dit

Dit meneer daar, kom dichter op die camera.

Laat ons net die abdomein weer inflate.

Neem dit meneer daar, dit meneer daar.

Nou, dit sal die kapasie dan soek draai en

maak as we nie vir die vloeide op daar leek.

En as daar nie bloed is, ja, dit seem soos,

ja, ok, ons het hier een paar portblied,

ons sal dit aanbewees.

Ek geef my die, no,

Nee.

Een fysieke afsluitingsapparaat?

Nee.

Heb jy, prof, ooit een probleem gesê met die pleura,

terwyl jy die seksie doen, of die lichaam

in die abdominale kabide neerslaan?

Heb ek ooit gesê, eh?

Lesions to the pleura.

Dis dit nie dit?

Lesions to the pleura vir pneumothorax.

O, jes, jes.

Especial with the redo surgery.

Often.

I would say more often than not.

Especially with the redo surgery.

We see it very often.

en speciaal met die groot hulmeer, jy weet, vaak sal jy vind met die groot hulmeer, jy, jy kan vind dat jy

eindig die pleer open, en ek is nie verantwoordelik over dit at al, wat ek doe, dit is my grootste indikatie

vir die gebruik van die verusneedel, wat ek vaak doe, oh, dit is, dit is, dit is nie goed,

sies, wat ek vaak doe, is, ek sal gewoon continue, jy weet, die neathetisme,

just cope with it then it's okay but then what i would often do is to uh to afterwards just put a

various needle into the second intercostal intercostal space aspirate the co2 and just do a

chest x-ray in the recovery room after the anesthetic because there is no lung leak i

don't put in a drain it's never necessary really never never never that's very very nice the lung of

course very good thought about the needle into the chest very good yeah and that also of course

helps you not puncturing the lung if you should be a bit wild but normally uh it's not a problem

good that's the uh the management of an intra-thoracic stomach

Well, poison, yeah.

Just pick that port up.

Oh, excuse me.

Someone takes a bite apart.

There we are.

Prof, excellent.

Really congratulations

for this very interesting case.

Oh, thank you.

And in your hands

it's been really simple.

This can be very difficult.

The next case we'll have

15 minuut, 20 minuut

break again. Ok. And the next case

we have is the patient with a

gastric diverticulum in the

fundus. Ok. That will

be our last case for the morning.

Well. Right. So we'll see you just now.

We look forward to speak to you again.

Say hello to all your team as you just

now. Good. Ok.

Bye bye prof. Bye bye.