Heide Van Der Walt

Ja, my dames en sê, nog, nog, nog, daar sê.

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

Focus, and I'll be back in a minute.

That's the Ziffy Sturnham over there, that's the rib edge over there, the rib edge over there.

O, the umbleik is down here as you can see.

So our first, daar sê.

It's about 12 to 14 cm from the rib edge over there.

Not the bottom of the syphus sternum but the top of the syphus sternum.

We're going to make an incision there.

en daar gaan we een incisie doen,

net vir een 8 mm poort,

en we gaan insufflate met een 5 mm poort,

in die begin,

en dan insufflate die,

die abdomen,

met een druk van 15 mm mercury,

dit is een groot buik,

die abdomen,

to a pressure of 15

millimeters mercury.

Oh, yeah.

Maybe we should

take a look.

We'll see.

Benicia Street.

Doek, that's quite a big building, this guy.

South Africa. Good.

Right now, our next port

is going to be for the camera.

And that's about 15 centimeters

from the top of the Ziffy.

And that's going to be

a 10 millimeter port. Good.

Right now,

Our next port is going to be for the camera, and that's about 15 centimeters from the top of the Ziffy,

and that's going to be a 10 millimeter port.

There's our camera going to go in now.

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

dit sal halfwege, dit is so'n semi-lunar halfcirkel, en dit sal een 5mm poort gaan.

Dan sal ons volgende poort tussen die camera poort en die insufflasie poort,

dit sal halfwege gaan, dit is so'n semi-lunar halfcirkel,

dit sal een 5mm poort gaan, dit is tussen die rib en die ziffi sternum,

en dan halverwege die 2 port,

laat ons sê hoe groot is die liver,

in die mid-axillary line,

dat is tussen die rib,

en die 5mm port hier,

is dat a 20mm,

of 26mm,

hier kan jy soos die 5mm port.

Dan gaan we die 5mm port hier,

vir die 8mm port,

en die reden waarom ek 8 mm port gebruik, is dat dit een 20 mm port is,

26 mm port, 10 mm camera port in die middelein, 15 cm laag,

een 5 mm port tussen die 2 ports, tussen die ZIFI en die RIPGAS,

een 8 mm port en een 5 mm port, 10 mm camera port in die middelein,

15 cm laag, 5 mm port tussen die 2 ports,

We are using a Olympus 3D system as you might have gathered from our spectacles that we have.

Ah, it's got a nice big floppy liver.

We actually got it to lose a bit of weight before the surgery.

Ah, it's got a nice big floppy liver.

We are going to use the Olympus Thunderbeat

because he was quite overweight clickfix

and he is not very tall anyway, but he is 115 kilos.

Open up the Pars Flacida

and we are going to use the Olympus Thunderbeat

and my instruments are the Storz clickfix.

Now we are going to open up the Pars Flacida

or the lesser of the other.

artere over there, we're just going to

cauterize that

Alright, there we are, good

There's a little artery over there

Right, now

there's the caudate of the liver

that's overlying our landmarks

over there

Right, there we are

Good, good

Right, now

over there

There we are

we are, I'll say, there we are, good, a little bit

fit, now we're going to open the right plane, there's one,

there you can see the posterior vagus coming through, a little bit

fit, that's our layer, that's where we have to go, there you

can see the posterior vagus coming through, just open up

there, there you can see the posterior vagus, that's our

We open die laag, dit is waar we naartoe moet gaan.

Goed, sê dit daar.

Just open daar.

Daar kan jy die posteriëre vagus nerve sê.

Ek gaan die laag open, sê dit daar.

Nou sê ons,

die kruis die kruis

op die

linkse sê.

Ek sal die esophagus daar aankop.

Nou sê ons,

die kruis die kruis,

sê dit hier,

op die

linkse sê,

en loosend op die soficus.

We'll do that.

Het is beter.

We'll do that.

Let's see how my poma we.

Loosend op die soficus.

We'll do that.

Het is beter.

We've got quite a lot of fat around the soficus.

There we are.

Let's see how that is now.

There is the nerve.

Alright.

Good.

I'm going to take the short gas.

If I do a

heller myotomy,

I usually do it to pay.

If you do a door,

you probably don't need to take

the short gas.

I'm going to take the short gas.

If you do the door,

if I do a heller myotomy,

I usually do it to pay.

Die?

Woe.

Here we go.

Ja.

Nou jy lie, eindlik heb ek jy een druk as jy nie.

Ja.

Nou, probeer opstaan.

Ja nie, die druk nogal erg nie.

Woe.

Alright.

Ja.

Ja.

Nou, probeer opstaan.

Ek kan nie wat hier sê nie.

Piero, we have difficulty in hearing your voice.

I'm sorry.

Kan jy wat te sê nie?

Oh, my heart, I'm sorry.

The length of my mouth to me.

I usually do at least 5 millimeters proximal, usually much more, and too distally.

So, I abolish the lower esophageal sphincter completely, because I'm going to do anti-reinfocts procedure.

The old story of sphincters, usually much more, and two distally, so I abolish the lower esophageal sphincter completely.

I always do a proper, because I'm going to do anti-reinfocts procedure.

And of course, if it's a type 2 or type 3 sphincters, one distally on the stomach, then I go up quite a bit higher, completely my esophagus.

Sofagus, up to 10 centimeters sometimes.

I always do a proper

3 and 8 size.

And of course, if it's a stomach

to type 3, especially type 3

glasia, then I go

quite a bit higher.

Up to 10 centimeters sometimes.

Depending on what we see.

3 and 8 size.

So there's our stomach.

And this

loosened.

There we are.

But first, why does all the esophagus

as jy net die myotomie doen en daarna,

dit is gericht.

Why?

Why, as jy die toupee doen, is die probleem daarvan?

Jy moet die toupee doen.

10 cm, 8, 10.

Jy moet die toupee doen.

Dit is gericht.

Ek vraag, sorry.

Ek het nie begreip, ek dacht ek praat om die toupee.

10 cm, 8, 10.

Ok, so daar, we het die esophagus,

Hier is die fattie pad, die fundus van die stem.

Die eerste stap wat we gaan doen is om die mark te doen.

Jy kan sê die patiënt ook as een rather groot aeitis.

So daar is die aesophagus, hier is die fattie pad, die fundus van die stem.

En wat ek normaal doen is, die eerste stap wat we gaan doen is om die mark te doen.

So despite the fact that he has achalasia, we are going to close up his eyes, and what I normally do is I close up his eyes so that 50% of the space is occupied by the esophagus and 50% space over there and over there.

Now again the position of the myotomy, traditionally the original hella myotomy was taking the

fattie pad, trans-thoracic, en die

helle myotomie was on die left side

to divide

myotomie, sling fibres.

Lapiscopically,

most surgeons actually

work on the

trans-thoracic, and the

helle myotomie was on the left side

to divide

clasp fibres, the sling fibres.

I do it on the left hand side,

most surgeons actually

right side of the esophagus,

over daar en hulle vervang wat ons die klasp noem. Ek gaan lateraal na die vagus nerf, ek doe dit

op die linkere kant, ek hou van, wat ons gaan doen, is om te begin met die vat pad te vervang en ek gaan

na die linkere kant, dit is ons vagus nerf, die vervang over daar, vervang die vat,

so ek gaan lateraal na die vagus nerf, ek gebruik dit ook om traksie te doen, so wat ons gaan

doen, is om te begin met die vat pad te vervang, we gaan direct na die lichaam

een klein laai van vat hier, en ek gaan net die superficiele laai met energie, en dit is die enige

energie wat ek gaan gebruik na die esophagus, net om die muskel te verslaan, so dat ons kan werk en

goed sê wat ons doen. Ek kan sê dat hier een klein laai van vat hier is, ek gaan net die superficiele laai

met energie divide, en dit is die enige energie wat ek gaan gebruik na die esophagus, net om die muskel

So that you can work and see properly what you're doing.

Now, I'm going to grab that one over there.

Right, you can see the liver of the patient is a bit big.

I actually grab the vagus as you can see.

I use that for traction.

Shift that liver retractor into a better position over there.

Right.

Right.

So we've got that over there.

Dividing the fat.

I actually grab the vagus as you can see.

I use that for traction.

Thank you, that was awesome.

Right, we're just going to clean the lens at this stage.

Just going to loosen that.

Just the fat.

Okay.

Again, the lens.

Divide the fat, 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.

Let's deflate the abdomen.

You can just touch the mucosa of the stomach.

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

which was wondering why you're doing a toupee rather than a door.

they have quite a high incidence of reflux afterwards and uh what else happens if you do the toy

i just hang on the esophagus i actually as i said i like this obviously uh i've actually uh i know

i've got no double but they have quite a high study flux afterwards but my and my initial happens

if you do the door these patients they have a little esophagus dysphagia and actually and that's

why this is you know switched and uh i know i've got no double randomized study to prove

my initial thoughts were that these patients have a little bit more choice

but I mean there are many surgeons that actually rather do a toupee than a door

I just prefer the toupee

if it comes to the achalasia

Goed, nou gaan we beginnen met die myotomie.

Ek sal net die muskel divideer, jy kan sê hoe sterk dit muskel is,

soos dit, ek sê dit opnieuw.

Dit is een typieke akalase wat soms meer dan 1 cm groot is,

jy kan sê hoe sterk dit muskel is,

Sofogus.

Ja.

Ja, 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.

Yeah, I've actually had patients

with squamous cell carcinomas

and it's quite interesting.

One patient had a carcinoma

We did a resection for that specific patient right down to 47 years ago, very very long carcinoma, but he actually did superficial.

But as I said, we did a resection for him for that specific patient was about 5-7 years ago,

They're usually more superficial

and well, we know the incidence

of squamous cell carcinomas is 20 times

higher. As I said, it's

in Achilles and compared to

your normal population. So

typical squamous cell carcinomas. They need to be followed

up. They're usually more superficial

and well, we know the incidence

of squamous cell carcinomas is 20 times

higher if you're

in Achilles and compared to your normal

population. So

they need to be followed up

but the problem is the carcinoma

en hulle klop op en

klop op vryg.

En as jy kan sê,

een minimaal bloeding,

en die bloeding stopt

vryg, ja,

want jy rupt hier die,

ja,

die vessel.

En hulle klop op.

Ja, hy het een

asiatik tube, ja.

Ja,

die stilte van die

myotomy,

is dat jy moet

op en neer

tot jou eerste

Mycose of the esophagus is quite strong.

It can probably take a little burn or two.

It probably bleeds a bit.

But if you bring any energy,

just pinch it, keep it for a while,

you can see I don't use any energy on the esophagus whatsoever.

By tomorrow it's going to suffer.

The mycose of the esophagus is quite strong.

It can probably take a little burn or two.

But if you bring any energy near this gastric mycose,

you can see it's bleeding a bit,

it might look okay today,

but by tomorrow it's going to suffer.

And then you have problems.

So hy moeie whip daar so nie.

Right.

I think we load down here.

Now that little bleeder.

We're just going to keep that for a while.

And wait for it to stop bleeding.

That's all.

Don't burn it.

Don't be tempted to burn it.

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

Now that little bleeder.

Maybe not today.

But for sure tomorrow.

Keep that for a while.

And wait for it to stop bleeding.

With any other pneumatic crap.

Don't burn it.

Don't be tempted to burn it.

to check the mucosa or not?

No, I don't use a scope

or anything like that for sure to one.

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

the first thing that the patient gets

is, I guess, a barium swallow.

To check the mucosa or not?

A few reasons. First of all,

to document and make sure that you have

proper through flow, and what I do

is, on day one, tomorrow morning,

the first thing that the patient gets

is a barium swallow.

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, right, now we're going to start off with a pure fluid diet.

His liver, he's really got a big liver, this guy.

Okay, 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 hiatal repair.

We're just going to have to do something about

his liver. He's really going to be liver, this guy.

Okay.

Okay.

As a typical South African rugby

liver.

You are

a top piece with the

World Cup, isn't it? Yes.

Yeah, we're doing quite well

at the moment. As usual.

As a typical South African rugby liver.

15% of patients with achalasia also have hiatus hernia.

Is there any association between the achalasia and hiatus hernia, or just in this case?

Well, 15% of patients with achalasia also have hiatus hernias.

So, what I'm using here is a Ticron 1 on a 26mm needle.

It's a cardiovascular CV suture.

But, 15%.

I'm picking up the esophagus to present.

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

Right, I'm picking up the esophagus to present the, you must take large bites, taking its muscle, good solid bite at the bottom, otherwise it tears out very easily.

Right, and now we're going to knot, there as well, and you must take large bites, its muscle, otherwise it tears out very easily.

Arrof sake tafels, so pikie vir my.

Right, and now we're going to knot, let's just clean that lens again.

This is now the liver that's crying, net so pikie af.

Stop, naasie, dankie.

on of sake tafels of bikkie van my uh let's just clean that lens again this is now the liver that's

crying need to begin let's go closer all right let's go closer going to put another stitch

there i think two two switches will be necessary to close up the scientists a bit see that oh no

okay let's just clean another stitch there i think two switches will be necessary

see to close up. There is still a lot of suturing to be done. Maybe we should have done a door.

Easier. See that. Oh no. Okay. Let's just clean that lens again. And there is still a lot of

suturing to be done. Maybe we should have done a door. Easier.

Oh there. Okay. You see the water lying over there? Oh there. You see the water lying over there?

Let me just finish here.

Take it right out.

Clean the lens.

That's last half.

Let me just finish here.

Take it right out.

Clean the lens.

Here we are.

I think there's going to be a kill.

Let me just quickly clean up the blood bath.

Here we are.

I think there's going to be a kill.

There we can see.

It's about a 50.

The blood bath.

50-50.

That's the vagus nerves.

Right there we can see.

It's about 50, 50, 50.

As the vagus lives.

Okay, hold that one like that.

Okay, hold that one like that.

Okay.

We're going to fix the stomach to the cruciate top there.

Just above the top suture.

Let's close the hiatus.

Let's close the hiatus.

Oh, we must add drop.

Kom, kijk nou in.

die lens opnieuw maak, mooi en kort nie, dit is daar gaan, radio,

oh, laat ons dit net so hou, net die lens opnieuw maak, nou gaan we daar nou gaan,

ons moet die lens opnieuw maak, dit is daar gaan, en laat ons dit so hou,

Just clean the lens again.

Why not?

I'm concerning

other possibility

to do this

kind of treatment

what is the best still

surgery or comparing

to the poem.

I'm concerning

to do this

what is the best still

surgery or comparing

en die ander ding is dat hulle reflux.

Die probleem van die PPI is dat

ons gastroenteroloogies

nie so keurig om dit te doen en

dan ook, we het veel verkeers,

so hulle eindig met die LMI-automie

en die ander probleem is dat

hulle op PPI is

en we het veel verkeers

en dan ook, we het veel verkeers

want die PPI-gebruik, die radiologiske betekenis, is net nie so goed als wanneer jy dit procedure doen.

Maar op die BAM-swallers wat jy post, is die radiologiske betekenis net nie so goed als wanneer jy dit procedure doen.

poems but my guest entherologist yeah then they're not my hospitals they actually stop doing nearly

as open they see all the agencies to me like this so we did poems but my guest entherologist yeah

see this suture that i'm putting here i'm actually taking around the vagus nerve they send all the

achilles because the muscle of course is quite weak and uh with the toupee that can i mean one

One cough it can tear out.

You can see this suture that I'm putting here.

I'm actually taking around the vagus nerve.

And as I say, include the vagus nerve there.

Because the muscle of course is quite weak.

And I know it's not going to tear out.

And it's going to keep it down here.

I mean one cough it can tear out.

So you have to be,

take a good piece of muscle.

And as I say,

the vagus nerve there,

the stomach here on the right side.

Then I know it's not going to tear out

and it's going to keep it down here.

I just use two switches

to fixate the stomach

here on the right side.

Of course,

no drainage isn't it?

I beg your pardon?

No drainage.

No drainage.

No drainage.

Usually by the time that you finished,

all this bleeding is cleared out.

Of course,

I beg your pardon?

No drainage.

with the

and we'll just finish this one

and then we'll

by the way

on the external view, outside view

I could see, it looks like

there is a sort of

bionic hand

to deliver something

new

I've been using this for years

I could see, it looks like there is a

soort oor bionik

hand to

deliver something new.

It works with compressed air.

I've been using this for years.

You've got a button that you can push here

and you can just shift it in position.

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

and it will show you, freeze is solid in that position.

It's made by Braun.

It works with compressed air

and you've got a button

that you can push here and you can just

shift it in position.

en dit vlees solide in die positie.

Dit is nie so mooi as een assistente?

Oh nee, jy sal my assistente sê.

Dit is nie laas, dit houd die tensie al die tyd

en dit sal nie die liwe laas.

Maar dit is nie so mooi as een assistente?

Oh nee, jy sal my assistente sê.

Maar jy sê, ek het maal assistente gehad

totdat ek jou met jy het gekom,

en dan het jy my die juiste manier geleid.

Now I don't have any males in my theater

Good, good, good choice

But you see

I used to have male assistants

Until I met you, P.O.

And then you taught me the right way

Good choice

Right, we have to

Reposition this

I think the end

Cleans the lens

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

That's it.

Right, we have to

just reposition this.

DJ, sit om vir my weer oor op

die lens.

Buiten.

Oké.

DJ, sit om vir my weer oor op

die

buiten.

Oké.

See, now this one, I just use it like that.

Put it into position.

Op die position, ek klamp my liver retractor en ek laas dit en dit is solid.

Lovies instrument.

See nou dit, Never lazy always listens to me en doe die job best goed.

Ek klamp my liver retractor en ek laas dit en dit is solid.

En dit blijft stil.

Dit blijft stil.

Ja.

Lovies instrument.

Never lazy always listens to me en doe die job best goed.

Jy kan sê die mykose balking uit mooi hier.

over here. It keeps quiet.

It keeps very quiet.

Very quiet.

Never criticizes

me either. You can see

the mucosa bulging out beautifully over here.

Ok.

Careful to not stick a hole into the esophagus

over there. Careful to

not stick a hole into the esophagus over there.

This, by the way, if I do

a toupee

as an anti-reflux procedure,

I use exactly the same technique.

It's just the closure of the

die hiatus is natuurlijk anders.

Dit, by die man, as ek dit te paie doe,

as

een anti-reflex procedure,

ek gebruik exact die same techniek.

Die sluusie van die hiatus

is natuurlijk anders.

Dr. Rousseau, die is vir my verantwoord,

is verantwoord, hoe kom

jy so myne stikjes daarboor

verantwoord, dat dit

stenosis en fibrosis

is?

is vir my verantwoord,

is vir my verantwoord,

hoe kom

They get parasophageal hernia

and the thing is, if you don't do

your toupee properly,

they reflux.

If you don't do a proper

anti-reflux procedure,

if you don't toupee, of course,

your toupee properly,

they reflux.

They have to do a proper

anti-reflux procedure.

It was good about the same type of procedure.

The door is an

in de buitenkant van die

esophage systeem.

Die toupee is een buitenkant

van die esophage systeem.

Maar jy moet

die systeem,

anders kom dit los.

Want herinner jy,

jy systeem

daar,

en dit is nie heel sterk,

maar jy moet die systeem

proper, anders kom dit los.

jy systeem daar,

muscle ja, en dit is

not very strong

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

I'm back.

Sure, his liver is in the way again.

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 C-suites on the left-hand side.

Daar kan jy sê hoeveel myotomie geexposeerd is, daar is jou toepie, en dit goes right down to the stomach area, down to our first blood vessel, which we demonstrated there.

Here you can see how there is your landmark for your distal mark of your myotomy.

And you can see it burns right down to your stomach area.

Listen, there is a gastric when it's coming out.

It's coming out, yes.

There is your landmark for your distal mark of your myotomy.

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

It's coming out, yes.

Straight away.

Straight away.

vir bloeding, niets daar,

we gaan net wat lokaal,

niets aan die sida,

en dit conclude die procedure,

en dan gaan we net check our port sites,

en by die man, dit is veel sneller dan een poem,

nie daar,

as hy poms doen, dit neemt een uur tot twee uur,

nie aan die sida,

right, thank you very much,

thanks,

en by die man, dit is veel sneller dan een poem,

Listen, are you going to show us other cases?

I have another achalasia, which we are going to do after this case.

We are going to keep him in our hospital for a week, to clear his achalasia from his birthened gable.

We are just going to switch over

and then I'm going to do another

but this is often also the patient

that you might at this stage

consider to keep in the hospital

for a week to clear

his esophagus from all the food

and debris that is in the esophagus.

Of course the other option is esophage

consider for a esophagus

to make sure that they

are able to swallow.

Thanks very much.

in how long

are we going to be ready

in how long

10 minutes

let's make 15

for a great cup of tea

thanks very much

are we going to be ready