van der Walt

Most of her symptoms was nocturnal

when she went to bed

and she was also one of the patients that sometimes

had to sit and sleep and she couldn't lie down.

So what we're going to do is

if we can have the camera over here on the stomach

right here on my hand

right, there is

the rib cage over there

the ziphy sternum is over here

the confluence is over there

there is the umbilicus

so that is kephalic in that corner

our first port

is ongeveer 12-14 cm van die hoek van die Ziphysternum.

We draai die skyn over en maak daar een klein inzicht,

want nou is dit oor die ribs,

want dit is die ribkage daar,

maar as die lichaam inflate,

dan bewees dit oor die ribs.

Hoi Peter, dit is my anesthetist.

Ek sal jou aan ons team aansluit.

So wat ons gaan doen,

is die lichaam nou insuflate

and I use a 5mm port

through Palmer's Point.

Now, a tip that we've got here,

Peter Kearney is the anesthetist,

one of my registrars is

Frans, Frans, pronounce your

surname.

Ok, you got it.

And then we have

Helene Genis, alias

Helene, as our

theater sister, and what's your name again?

Lisa,

is my cameraman on my right hand

with surgery.

Lisa must be your preferred, because don't remember her name.

Yes, of course.

Normally, as you know, Peter, I have a complete female team.

Theater sister, assistants, everything.

But unfortunately I couldn't supply a female registrar for this month,

so we have to make do with another man over here.

But, you know, these are the problems we have in life.

Yeah, but...

Right.

Now what we're going to do is to insert the camera port.

Dit is gaan word, oorweer, van die boek van die ziefesteunem, die konfluence van die ribkeg, in andere woorde,

en dit is gaan word 15 cm in die middelsteunem, en dit is een 10 mm poort.

Nou, we maak hier 10 mm poort, en as ek door die schief gaan,

ek het dit oor die spleen geanguleer om te sê dat ek nie ek nie groot bladwessels of organs het.

Ein, wat is die risiko wanneer jy die eerste trokker blind maak?

Ek het dit met 5mm lens al vele jare gebruik en ek ontvang die gevoel,

jy kan dit eindelijk gevoel het wanneer dit door die peritoneum gaan, dit is net so'n kleine snap,

dit is net so'n gevoel wanneer jy een pen door so'n plastic maak,

en jy het daar vat in, en daar is geen echte organ wat jy kan vermoed,

and I have now really done literally

thousands by blind entity

without any adverse outcome

whatsoever. And if you

just concentrate, you must control

your port so that you don't put it

in too deep. That's the first thing.

And the second thing is, when you put it through

you must be very aware of that feeling

because you get like a click click feeling

when it goes through. Very much like we get

with a varus needle if you go through

the umbilicus. Same type of feeling.

And what is also good is, if you go

through on the rib cage, the muscles

en alles is fixeerd hier, so

jy kan nie vir die diep gaan, soos

as jy in die middel van die abdomen gaan,

jy kan vir die ding vir die diep

in die abdomen, en jy

nie het dit, want die ribs

splint die abdominal wall

superiërly.

Right, nou gaan we in met die 5 mm.

Die goeie trik.

So nou het ons...

To pull over the skin, of course.

Ja, so dit is

dan die 5 mm om te start

met. Dit is die 10 mm

for the camera there, a 5mm

between these two, and then

between the ziffy sternum and the ribs, in that

little corner over there, we put

another 5mm, and between these two

there's a mid-rectus,

put another 5, again with

control, and here's our

8mm, and the reason

why I put in a 8mm here, and we

of course going and watching all

these ports as we go through,

but the 8mm is because

this is the smallest port

26 mm neel kan neergeweer.

So, basicly, we use

1.8, 3.5s

and a 10 mm.

So, that's our port placement

and this is my standard port placement

for all

anti-reflux surgeries.

You'll also see that I'm standing on the left side

of the patient, next to the patient,

not in the French position

between the legs.

We can discuss the reasons for that.

The patient is head up, isn't it?

The patient is head up.

The patient at the moment is head up

and tilted slightly towards me.

As a matter of fact,

I think she is actually fine.

But it's about a 20 degree, 25 degree tilt

and usually about 10 to 15 degrees lateral tilt.

Alright, and then once we've got,

we've now inserted our liver attractors,

I think we can switch to the inside picture now.

Yeah, we're in.

I can see you very well.

Okay.

Inside.

Right.

Now, there's our hernia.

Right.

As you can see, this is now slightly reduced because she's ventilated.

But when I saw the patient initially, you know, this whole stomach was up in there.

Right.

Okay, our first step is going to be to divide the lesser momentum, the pars flacida.

I use the Thunderbeat, but you can use any energy device.

I find that the Thunderbeat's speed and effectiveness is a bit superior to some of the others on the market at the moment.

I think they have a bit of a leading edge.

There's some fat there, but we're going to leave that.

So we go down to the diaphragm over there.

Now we move back a bit.

Now one thing about these patients that

usually come in with these interthoracic stomachs

or giant hernias, they are

often patients who are slightly

overweight as well, or sometimes grossly

overweight. Now our next step is

to open the edge of the diaphragm over

there, the cruz,

and that's the white line that we're going to follow

there, and there it's coming into view,

we're opening it up, and it doesn't

matter how big the hernia is, and I'll demonstrate

this with all these cases that we're going to do

over the next two days, the esophagus

always lies in a position to

the cruz on the right side.

If you go and look for the esophagus

from the left side,

you're in a lot of fat,

it's a big cavity, the aorta

is there, it's a

mess to try and find it from that side, it's blind.

You open here, you always

have the esophagus in place

and touching the cruz

on the right side.

The other thing, the first thing that comes into view

as well is the

vagus nerve,

there you can see the vagus nerve,

right, the patient has a double vagus nerve

there, so what we're going to do

is just to sweep that fat over there,

and use our instruments

just create a space

between the stomach

and the pleura on the side.

Now again with these large hernias

you can get a pneumothorax,

but the size of the hernia

often protects

the pleura

are from being open there the patient has quite a bit of a lipoma there just going to divide this

and how do you dissect then the sec i'm going to show you there is a specific there's a specific

technique that i use to do this which is different there we have a what is that now that's just a

sack over there i just want to open up the cruise there and just identify it there we have it right

Ok, nou wat ons doen vir die zak, is ek gaan dit patie pad vir hier eerst neem, en ek hou dit soos dit,

nie te hard neem, en nou gaan we dit soos dit, met die esophagus, en wat ons doen is,

just stay on the edge of this sack all the time, you'll see that I'm not trying to reduce the stomach,

I leave the stomach inside the chest, because once you reduce the stomach, I mean, this is not,

nie, jy sal sê dat ons wat grieke herniers kom, dit is een van die kleinere voor

vandag, wat gebeur is, dat ons net die lichaam daar verlaat, en ek sê net die

saak, dit is al wat ek doen, goed, daar is die saak, so we vervang die saak,

koncentreer op die saak, en we kom naast op die kruis, op die

En dit is net met wat losse diseksie, en ons continue dit al die tyd te divideer, om die kruis te voorkom,

divideer wat van die losse arteriële tisje daar.

Ok, so, just houd dit so, continue die diseksie, en dan kan jy tot die korn,

en by die tyd jy hier, is die stemme automatiek vervormd.

by itself now what we're going to do is to loosen the adhesions over here and these patients usually

have long stitched out short gastric vessels as you can see over here so we're going to buy these

Just taking that one over there.

Faction there.

The second area over here.

And I'm just picking up this part of the esophagus.

Divide.

You find often adhesions with the pleura,

with the left pleura.

Ah, yes.

But as I say,

what happens here is with these big hernias,

and I'll show you now,

it usually pushes away the pleura.

Just look in there.

we are looking in from the

left side of the patient

but there is the pleura right

at the back there, see it's far

out of the way, and the same on

this side, so there is the aorta

right, but the

hernia actually pushes the pleura

away, so I think you probably

have less of these problems

of anemothorax compared

to your normal situations

alright, now the next thing

that I'm going to do, and you can see there is a big fatty

pad hier as

oh dat

is a very good protraction also

yes

pasien druk

I'm dividing this on the

fundus

I'm dividing this layer over here

to free the fundus

and free this fatty pad on this side

and the reason for that is

if you don't do this

and you try and swing the stomach around

can you see what I've done

if you don't do this and you try to swing the stomach around

this whole piece of fat goes around and it's in over there and then you can't do a proper nissen

right let's just have a look at this this is fine that's also that's some of the vessels there

all right so we've delivered the sack and now what we're going to do is just loosen the

esophagus a bit from the surrounding adhesions no so again you can see there is the pleura

right on the side over there right way out of the way and you can see the big cavity that we

have here the same with the player over here the player is far far away push away there's the air

water is absolutely clear yeah congratulations for that right france it's just that one down like that

there you can see the anterior vagus nerve with these big hernias often the nerves tether the

the esophagus, and you have to cut

the nerves to get this length on the esophagus.

I'm sure we're going to have

one or two cases like that today.

How far up do you go to the

mobilized esophagus?

I usually go, yeah,

I usually, I do quite a high

mobilization in these cases, because

if you go and look here,

the Z-line is over there.

These white fibers are stomach,

the pink fibers is esophagus.

So this esophagus is

a bit short. So therefore,

Daarom sal ek dit op een beetje laag verloos, om een beetje lengte te kry op die esophagus.

En dit sal jou help?

En ek sal vaak op ...

Sorry, die seksie, die hiede seksie, sal jou help om,

nie in dit geval, maar in andere geval, om die colis te doen?

Jy weet, Peter, ek doe nie meer colises.

Die resultate van die colis is virgelijk abysmal bad.

Wat ek sal doen, is, as ek een patiënt het met een korte esophagus,

I would operate him

bring it down as far as I can

and fixate it

and then I give the patient a year or so

to recover and wait for that esophagus

to become supple again

and often when you come back with a second operation

you can win 5 or 6 centimeters

on that esophagus

and

then I'll redo the patient

take the nissen down

get the length of the esophagus

and you can usually get it down

with a second operation in a small portion

moet jy een derde operasie nodig het.

Maar dit geef jy een baie, baie betere

langterm

uitkomst. So wat ek doen is,

ek doe nie meer Colis-Nissens,

ek doe dit

follow-up techniek,

wat ek vir jy geskryf het.

So dit is 2 stages operasie, of 3?

Ja, dit is waar.

Ja, ja, en hulle doen

baie beter dan die Colis, want jy weet,

met die Colis, ek bedoel, soms dat

riemelik stem dat jy probeer

make a new esophagus from.

It

stenosis. It's a

avascular, a peristaltic

segment in the esophagus,

so they've got a high incidence of dysphagia.

It produces acid,

and even if you've got a fantastic valve there,

they still complain about heartburn

and acid. So that makes it

a, and then some of

them actually with the

collis nissen, the nissen gives

you resistance,

resistance, and what happens is that

distal piece

of new esophagus made from the stomach

blows out and

becomes a big pouch

and blows up in the abdomen, it's

like putting a nissen on an echolasia

they have severe

dysphagia, and then they have retention

of food in the esophagus, no

it's a mess

and quite a significant

amount of them actually

end up with a resection

just to get rid of all the complications

van die nissen, so ek doen nie

nissen, collis nissens nie meer

ok, nou gaan we dit knot

dit, daar is ons stik, hier in die

V, maak nie dat we dit

door die aorta

virste loop is pronating, put die loop

to the bottom, needle luller to the bottom

that one to the bottom, we take that one, we put it

through, then we supinate, loop

to the top, needle luller goes

to the top, we take that

and we have a square knot, right

then I capsize the knot into a

sliding knot, ek praat terug op dit en ek klik die knot, laat ons dit nogmaals doen, dit is een les in knotting,

want dit is een goeie leksioen, een echte goeie leksioen,

dit was laag, o my god,

ok, ons gaan dit nogmaals doen, loop naar die bodem door te pronate, as jy supernate,

jy neem die loop naar die boek, pronate loop naar die bodem, breng die knie al die

het door, het daar, pak dit op, neem dit op en breng dit terug door die loop,

goed, dan supinate, neem dit oor die boek, kom van die buitenkant, neem dit oor die boek, neem dit

en soos dit, goed, so ek het hier een suture geplaat om net die krure te vervang, dan het die volgende ding wat

ek wil doen, oh, ja, dit is iets wat ek wil jy toekom, as jy oor die lichaam soos hier,

jy sê dit transverse kleinje hier, hier is die wit fieber, dit is die pink fieber, dit is waar

jou z-lijn is, so dit is sofokis is een beetje kort, nou gaan we dit soos daarna

neem, houd ons soos dit frans, goed, en nou wat ons doen, is ons maak moestelik

die aantere repair in hierdie geval, en dit suture is nie transverse , ek gesê dit techniek, dit is nou

45 degries. So we take a big good bite from the cruis over there, upside down the needle, 45

degrees across, and a good bite of the cruis at the top. You must take big bites, otherwise it tears out.

And you can see the cruis, it's lying 45 degrees, eh? Now we pull that through. Now again, I've developed

a technique here, so that you can put it on stretch, because if you don't put that aetis on stretch,

your stitch is not placed in the correct position so we do the same again loop to the bottom needle

over to the bottom from the outside needle over to the bottom grab that one and we pull it through we

leave that one long then supinate didn't loop to the top needle over to the top grab that one put it

through we capsize the knot right then what I do is I put that on stretch over there like that see

See, and I tighten

the suture. Otherwise

it sits too high.

Peter, did you receive the documents I sent

you through today and yesterday?

Yeah, I enjoyed it very much, thanks a lot.

And you?

Yes, yes, very much. It's something

best professional information

I've received in a long time.

Just to relax a little bit in between cases.

Yes, that's right.

It's nice to read some nice things about medicine.

Yes, otherwise you forget.

That's it. We have to do

CME? Yes, absolutely.

Ok. Listen,

apart from this ayatoplast that you're

doing, any reason

or when do you think is

a reason to do augmentation

with

a web,

the prosthesis? Never.

Never. Never.

I've seen so many complications, I don't use mesh

anymore. Even staying

far from the esophagus?

Even staying far from the esophagus.

If I use this technique, I'm telling you,

Ek het duizend van die dinge gedaan, en daarom sê ek vir jy al die grieke herniers,

dat jy hulle kan klose, as jy geen prosthesis het.

As jy dit techniek gebruik, klose dit op, en ek sê, dit is een sterk techniek,

hulle brek nie makkelik, en as jy sê, ek het 2 struks in daar,

en ek sal probleem gaan, in die 3e aswel,

om te make sure, dat die anterioor hole is geklosed op,

en soms, die holes are so groot,

dat we 4 of 5 struks in die anterioor hole,

and you must put anterior switches

because if you try to do this with

posterior, you

know the weak link in your hiatus

is in actual fact this

arc of the cruce over there

and that's where they stretch out

so if you switch them posteriorly

it just stretches out to the front again

because you're not reinforcing the weak

weak area of the diaphragm

because the two weak areas of the diaphragm

is the

left cruce

and the arch of the cruce

of the arch of the hiatus

again there, look at those vessels

that transverse vessels

that's your telltale of where the

junction between the esophagus

and the stomach is

yeah, it is indeed the excellent

landmark

because the problem is that a lot of people

actually, you see this tube

and they think this is esophagus

and they end up doing the nissen over here

and then when you scope the patient afterwards

you still got a 2-3 cm

hiatus hernia

Because the wrap was put around the stomach

And not around the esophagus

And that procedure is called a slip nissen apparently

There is no such thing as a slip nissen

These are nissens that were done too low to start off with

A slip nissen is a very very rare finding

When you reoperate the slip nissen

You can always find that the operation was actually done

In the incorrect position

Right now you can see

Despite the three stitches at the top

We still have quite a bit of space at the back here

and we're going to close that up now.

Good big bite through the

height of the cruz.

or anything else?

Very much the same.

There is an operation

that I do

where I actually do a combination operation

to

make that

a bit better

but I didn't

and that I usually, you see you can never

predict with a first operation

wether the crude rate is going to last or not.

You might think it's weak

and you end up never having a problem with that patient.

And then you get the patient that you think

this is one of the best repairs you've ever done,

this patient will never have a problem.

And six months later you see them with a parasophageal hernia.

So I think it's very difficult to predict

because there are so many other factors that come into play.

But you can usually, if the patient breaks down

and develops a hernia again,

I mean, that's one way of really identifying the patient that has very weak crudae.

So in that case, you'll probably do a bit more work, maybe a bit more stitching,

try and see why did it actually break down,

and it's often because the hiatus was left too big.

Because you know, again, the hiatus is a circle,

and Laplace's law is very important,

and Laplace's law says that the tension in the wall is two times the pressure times the radius.

In andere woorde, as jy die hole een beetje te groot maak, dan het jy nie veel druk nodig om die hole te open te maak, terwyl jy, en hier kan jy sê, wat ek doen is, ek probeer het open te laat, so ek kan twee instrumenten neem, en in die esophagus is een FG-18 nasogastieke tube.

Daar is ons tube.

So met die tube en twee instrumenten, dat geef jy my saas.

But now you see it looks quite

tight at the moment

but I'll show you something in a minute

once we've done this operation

and finished it. Now what we do is

we take that stomach and you can see there is a stomach

that was loosened off the fatty pad

and that's put over there.

And you have to do that maneuver

so that if you put it through

you get the stomach through like that.

Because if you don't and you do

that and you pull this through

that whole fat pad

actually there you can see it, the whole fat

Pat Pat will come and lie on this side.

Pashendruk,

waar is Pieter Keunie?

Pieter?

Wach is,

ek skryf hier vir ons.

Sorry, just want to get that stomach again,

the front, you can hold it.

That one there.

Pashendruk,

I am sorry to trouble you.

Yes.

There is a question from another surgeon,

which wants to ask you something.

Hang on.

It's Dr. Marco Bargeri.

Yes.

Good morning.

Morning.

Good morning.

Good morning.

Good morning.

Good morning.

Good morning.

Good morning.

Good morning.

Thank you for your procedure.

I have two questions, if I don't

bother you. You said

you never put a mesh on the

hiatus. Yes, I don't do

that anymore. Neither a biological

or reabsorbable?

A biological mesh

doesn't work at all.

I've come back in those patients

when they re-herniate, and

we fix them with pigtails, and

the mesh is gone, and all you see is

the pigtails or the sutures that you put in there.

dit absorbeer volledig.

Voor een biologische werk ...

Nee, nie.

Nee, nie.

Dit is verantwoordelik.

En laat ek jy sê, ek het

wel over 100 van die mesjes gedaan

wat ek, jy weet,

opgevolgd het,

wat biologische?

Ek gebruik die van

Kaviria, en wat sê jy nou?

Ok, ok.

Metoo, ja.

Wat is dit?

Wat is dit?

Ek het dit al lang genoeg gebruik,

maar jy krij die 0.5 mm en die 1 mm.

Ja.

En ek gebruik die 1 mm en ek sê vir jy ...

Dit klink soos een pig.

Ja.

En ek kan jou een ander ding sê,

dat jy weet, ook met die incisione hernias,

waar dit,

daar is al een paar artikels gebied

publies, dat die

uitkomst met biologiske mesjes

vir lang term, ja, vir lang term

is, is vir vir vir poor

in verband met jou polypropylene

mesjes en so. En ek sê,

ek sê, jy hoef nie even

in die incisione te gebruik.

So, dit geef jy nie die fibrosis,

dit geef jy nie wat jy wil.

En ek kan

vir jou een goeie presentasie geef,

want ek moet jy een morgen geef,

en dit is oor die complikaaties van mes.

En ek nie, as jy nie weet hoe

to do esophage gastrectomy or

IVA Lewis, you shouldn't put in mesh

because that's going to be the next operation.

Ok, very clear.

The second question.

You always

associate

a fondoplication

for giant hernias

for type 3 hernias or not?

If a patient has not

a reflux.

Even if he has a reflux, yeah.

The reason why I do the anti-reflux

procedure is to anchor

the procedure at the bottom.

To prevent recurrence.

To prevent recurrence, because this gives

you, that's what you want, a nice

bulky thing, so it can't

go up again. Because often

these esophaguses are

a bit short, and you put a bit

of tension on it. Now let me show you there.

You see, it looked as if it was very tight.

Look how nice it is there.

So that's one centimeter there,

plus an 18 gauge

nasogastic tube.

and that's the size that I use

for these patients. They sometimes have dysphagia

but we deal with it.

Ok. It's a shorter

dysphagia? Ja, that's a

shorter, just first few days and so.

Ok. Right, so this is our

first case finished now. Thank you very much.

And we'll be back with

another intra-thoracic stomach

in a short while, or

a giant hernia.

Ein, thank you very much, but

I think I'm a little bit slower

vir ek het 30 minuut gehoor, jy weet nie?

Ja, maar ek praat hier veel, jy.

Ja.

Haha.

Haha.

Haha.

Right, Peter, we gaan...

Is hier camera?

Ja.

Ja.

We kan jy al sê.

Uh...

Ja.

Right, we have, uh, we have deflated stomach.

My assistant, uh, will suture the wounds.

I'm going to have a cup of tea and do some administration.

We'll get the next patient ready and we'll be with you in a short while again.

Ok, goed. Wat doen we met die administratie?

Niet met jou, exact.

Nou, ek het wat documents

dat ek vir jou gesend het,

wat ek jou nog oorheb.

Ok, ek vrede dit.

Dank u.

Dank u.

Ok, hou goed.

Ciao.