Prof. Heine van der Walt

all right what's peter hi hi hi peter on on the dot perfect yeah hi piero

fine fine nice to see you again and your stuff of course yeah i'll introduce you to all the

beautiful ladies in a minute yeah yeah of course one thing how come this year your uh your sister

sister there has got a face mask.

What's up? I don't know what's

going on. I'm going to take it off right now.

Anyways, are we on air yet?

Piero?

Yeah, we are.

We can see you.

I can hear you very well.

Okay, good.

Our first

patient that we have, we've got three

this afternoon. The first patient

is a patient who had surgery in

2010 it's 14 years ago and she presented a month or two ago with chest pain no

heartburn no reflux and on a validation she had a parasophageal hernia so we are

going to repair that now right okay let's get going thanks very much thank

you DJ I'd like you put to put your camera at the foot end of the bed so

So there, when you place our ports, you can just...

DJ, over here to put into the bed.

The camera over there.

By the way, Ayn, I send you on behalf of Professor Palazzini

his regards and thank you again for partaking to our comedy.

This is the 35th edition.

Yes, we've been coming quite a couple of years now, eh?

Well, as far as I know, I think it is 14 years.

Fourteen years.

Fourteen years.

The same as this operation, the same as this case, you know, it was them.

Yeah, that's right.

Here's our patient lying on her back.

I stand next to the patient on the left-hand side.

Our patient is tilted about 30 degrees anti-Trendelenburg and about 10, 15 degrees laterally towards me.

Pick up the patient, please.

Thank you.

Slightly towards my side.

Thank you.

All right, let me just quickly start the insufflation.

Our first port is on the rib edge with a bit of traction on the skin and palmar's point.

Right, and then the abdomen is inflated.

Right, our next port, that's the top of the zephyr sternum.

Our next port is 15 centimeters distally in the midline.

Sorry, the first operation was also done laparoscopically?

It was also done laparoscopically, yeah.

Okay.

Right, so that's our camera port, just going to swipe it lightly, bottom, right, keep it

on the outside picture, right, our second port is halfway between these two ports on

the left-hand side in a sort of a curve over here, right, so that's going to be over there,

and of course we've got the inside picture so I can see when my ports go in

right are you on the outside picture again you just stay there okay suck

that you want now we're going to place our liver retractor port that's the

zephyr sternum with a confluence of the costal cartilages are at the top end of

the zephyr sternum between the zephyr sternum and the costal cartilage in that

little triangle that's a five millimeter port and then halfway between these

ports in the mid-rectus area over there that's going to be our next port so this

is the assistance port the five millimeter port keep it on the outside

please now the XFU7 I'm in Te Ganwar right so that's the assistant port this

is the camera port these are the two working ports for the surgeon but I'm

going to remove this port and replace it with an eight millimeter port because

this is the size of the port that you need for a 26 millimeter needle and then

then I'm placing the liver retractor in the upper abdomen over there and the gas

thing goes on to the 8 millimeter port so we've got a five port technique

surgeons ports liver retractor port assistant port and then the camera port

over here right I think we can shift over to the internal picture right yeah

we can see there is the port for the liver tractor yes the port for the

assistant there's the gallbladder stomach and yell the two other ports for

the surgeon sorry yeah sorry I know and just out of

interest when you put all the trocats in do you have a second monitor or just go

as you will know blindly and very well of course no what we do is once we've

got the camera port in we actually go into the camera and then we put in all

the other ports under direct vision. Right, so there we're lifting up the left

liver lobe and you can see the adhesions from the previous surgery there.

Just securing the liver retractor and now the next step is to take down the

adhesions between the liver and the stomach. It's tenting a bit there.

somebody who's really got everything stuck here murphy's law let's look here there's the vena cava

right there we can see some of the sutures of the previous operation although as you said the liver

is stuck looks like the adhesions are quite flimsy yeah they're they're soft uh you know

after 14 years this is what you expect um over time of course it does become less and less

it can sometimes be extremely taxing we have I operated this patients myself 14

years ago the other two that are coming are sent elsewhere so we don't know what

the lucky packet is going to hold for us but we'll find out there you can already

already see right let's just open up here this is the fatty area we try and identify the fundus

of the stomach on this side by opening up this little window over here posterior to the stomach

fundus there we've got our axis over there it's starting to open up there's sutures on the other

side coming into view loosen that a bit okay we'll loosen that a bit better just now the challenge

with redo surgery is always to try and identify your vagus nerves which is often very difficult

and so often these are all the smaller parasophageal hernias as you'll see

that cause the pain because they go in and there's the fun is stuck

i'm going to loosen this now i i believe this patient had a gastroscopy study beforehand

Yes.

Was it evident and easy to diagnose it as a parasophageal hernia?

Yeah, it was very obvious.

It was very obvious.

On the look back, you had your esophagus, your intact nissen,

and the parasophageal hernia next to it.

It's quite, it's really much easier to see a parasophageal hernia with a scope

than it is with a barium swallow.

Right, there you can see.

Apart from chest pain, any cardiac symptom?

Nothing, just chest pain.

And the chest pain was related to eating habits.

She'd have pain after eating.

That's obviously when the pressure in the stomach increased,

then she developed pain.

Well, there you can see the zyte disc opened up quite a bit.

There's the reflection of the pleura of the right-hand side.

We don't want to open that.

on this side there it is just taking that back a bit there you can see the player over there

right and this is the stitches now if you look at the hiatus you can see this is uh i just want to

loosen this cruise a bit better right just keep that out of the way again

now if you look at this yeah because you always try to see why did the patient get a hernia again

I'm just going to replace that liver retractor a bit better, so I pick up the liver out of

the way, loosen that liver a bit more so we have more of the cruci exposed.

Now what you can see here is that all the sutures are sitting in the left cruci.

And if we look at here, this is separation of the cruci on this side.

So this cruci failed and this was probably the beginning of the aietis opening up like

that.

nissan is still intact with a gas gastroscopy we're just going to loosen the

the shoulders a bit can you identify the vagus yes i think we can here is the anterior vagus

you can see when you pull on it it it pulls in like that there it is right and on the posterior

side, I think that's our posterior vagus lying in this bundle over here, there it is, right,

that's in this fibrosis at the back here, so you don't want to divide that too much

because although it's usually plastered, you know, against the esophagus, you can often

see it going off at a slant on that side, which we can't see now, right, good, so let's

just loosen this, you can see how this is a piece of fundus that was wedged into the

esophagus into the chest from here up to there this is the the part that herniated all right

so i'm just going to loosen it to there over here i can show you the vagus very nicely now

just watch carefully if i pull that open there lies the vagus there you can see it right there

right there okay now i've turned the esophagus around you see this over here that is the posterior

here in Vegas, there you can see

it very clearly, right, so we're

not going to cut that off, right, I

think we've got the shells out there,

right, so,

can we have the nasogastric tube

in please, so we're not going to

redo the nissen, because the nissen

is actually quite intact

on the endoscopy,

there comes the nasogastric tube,

there you are, right,

taking that around there, there you are, fine,

you can leave the nasogastric tube

like it is, camera

out, clean, gas down, smoke out, here we are, just insufflating, we've deflated the abdomen

completely to get rid of the smoke and the fog and the vapour and whatever you call it,

and now we're going to suture up the hiatus and repair it, right, this is what we call

an entry level redo case, not too difficult actually, in your hand of course,

Right, now, very important, there's a nasogastric tube in the esophagus, it's an 18 gauge, pick

up the esophagus and the crurae, and pick up the crurae off the aorta that's lying over

there, otherwise you can end up putting your sutures through the aorta, not a good idea.

Right, so we want to present those crurae by picking up the esophagus, and it doesn't

help just putting a sling in there, you actually have to physically pick up and also stitch

the diaphragm itself in this sushi we're going to put in quite a bit deeper to grab that cruise

over there yeah i can see is it quite a big bite yeah you must do big bites

Yeah, you must take proper bites.

Otherwise, the first cough, it's out.

All right, did you suck out the blood, yeah?

I have the little switch over there.

All right.

This is as one tiger, isn't it?

This is?

is? Size 1

Ticron. Size 1 Ticron? Yeah. Yeah, the suture.

Yeah, the suture. On a 26mm needle

and it's a cardiovascular needle. Right, now

what we're going to do is we're going to do a repair anterior. You can see previously

it looks as if there might be a stitch there. But the big thing is to close

that hole now and we're going to do a combined anterior and posterior

here a repair. We're going to pick up the crux like that, that's the top of the esophagus there,

we're going to go in here, proper bite, then a reverse suture, put the traction there,

take, you can see this is very flimsy, this is nothing, the substance is over there. So we're

going to go in there, you can see it's stretched out now, we're going to make sure that we get a

good bite of the crux on that side. Now we're going to shift our liver retractor there to take

all the tension of the lateral walls of the of the career and you can see the

slant of this is 45 to 60 degrees so it's not transverse it's at the angle

and that's extremely important because you try sutures from side to side you

run into tension and the other thing is you want to pick up this cruise this is

the longer cruise this is the weak part it's always this cruise that opens up

that's why your parasophageal hernia always goes through on the left hand

side so I think I think this is a crucial point that you made very very

important and it's Laplace's law you know the tension in the wall is two

times the pressure times the radius so you want that the radius as small as

possible now we there you can see the suture now what I'm going to do is I'm

actually going to if you just pull this it sometimes goes very very across but

what I'm going to do is I'm going to pull the crew up like that keep it in

that position and then tighten my suture so that's nice and snugly around the bottom

not too difficult technique yeah yeah yeah

but it is it is something that you have to do here otherwise you end up with a very uh petulis

itis okay we can shift this one a little bit so i must say that the gap is really big yeah

Yeah. But now, as you can see, we're getting it together without any tension, or very little anyways, because that's the big thing is, of course, tension-free repair.

There's our suture. Again, getting enough substance there. Otherwise, they tear out, as you saw what happened posteriorly.

there. Okay, let's demonstrate the suture again. We're making a loop to the bottom,

bringing the needle over from the outside to the bottom, grabbing it and bringing it

back through the loop. Then loop to the top, take that one through to the top, take that,

bring it back through the loop, pull on the left-hand side so that you can slip your knot

important thing Piero is you'll see this is the subphrenic vein I always try to

put my suture sometimes you have to use it as a pledge and go above it but as a

rule your pericardium starts above it so you can always safely up to the edge of

the vein and at the bottom put a suture if you go higher than this you might be

going through the pericardium just an atomic landmark to help sorry sorry what what when was

that what do you say the separate symphonic vein ah yeah yeah yeah yes yes sure yeah there we go

through it not to worry about that because we don't have much screws there to suture anyway

way is a bit that you must really respect

because it can give

trouble. Yeah, no, for sure.

That's the only thing.

Alright, let's just take out that

switch over there.

That's not fast enough today.

Turn the needle around.

Bring it out over there.

Turn the needle around.

Into reverse gear. Now we're going to use

that. The vane is a pledged.

Alright.

Okay. We're going to leave that.

Take that over to that side.

all that from there this side and now we're going to go look what our hiatus

looks like behind this is fg-18 tubing there and we want to have at least one

centimeter behind if we open up there's one maybe a little bit tight this one so

that's a five millimeter instrument with a five millimeter gap there's a slightly

on the tight side but I'm actually gonna leave it like this because we didn't do

the nissen so that should be fine yeah to me looks fine at that gap i think it's just perfect i think

yeah that's right because once the tube is out of course there's also good enough space right

and we're not going to touch the nissen that's perfectly intact on the endoscopy as well and on

the manometry now we're just going to put a mixture of markane and magnesium sulfate into

the abdomen for local check our port sites for bleeding nothing over here over there and now we

remove the scope deflate the abdomen and that was our first redo i think the other two are going to

be quite a bit more difficult listen uh i think you are too slow i mean 25 minutes sorry i'm

I'm working on my speed.

Fantastic.

And it's perfect.

I mean, I don't know what to say.

Yeah.

Perfect.

Piero, we're probably going to change patients now.

Yes.

It's going to take about 20 minutes.

Right.

And then we'll be back for the next case.

Right.

So let's say around about 3 o'clock or so.

I mean, 4 for you, 16 hours for you.

Yeah.

That's right.

Yeah.

Okay.

Good.

Thanks.

Okay.

Thanks very much.

Yeah.