Heine van der Walt

Yes, I can feel it. It's uncomfortable.

Right. Is our couple there?

Yes, I think so.

That's fine.

Right. Is anybody on the other side?

Yes.

Here we are.

We're all about to see you again.

Good. This is another patient, again, presented, I think, by the cardiologist, this one.

And she also has an interthesic stomach.

She's 72 years old.

Again, no GERD, no reflux. That was not the problem.

chest pain was the problem and she ended up with a cardiologist

and again with a chest x-ray, a coincidental finding was the hiatus hernia

and well we're about to fix it

right

okay so that was 12 centimeters over there, 15 centimeters in the midline

that's for our 10 millimeter troco

she's got quite some stomach in her chest

Then we're going to put in a 5mm over here, a 5mm there in the little corner between the ribs and the zephyr sternum,

and a 5mm on the right side there between these two, a bit more lateral.

Patient always head up and tilted to the left.

I beg your pardon?

Patient is head up and tilted to the left.

That's correct, that's correct.

Right, we put in this grasper, pick up the tip of the liver.

Are we on the inside picture now?

Right, picking up the tip of the liver there, in with the liver retractor, picking it up like that, all that.

Right, let's have a look what's going on here.

Right, this patient has an aberrant left hepatic artery.

There's a little vein running over there.

You can see there's the B cavity.

and you know with anesthetic the stomach is reduced but if they have their normal

positive pressure inside the abdomen that whole stomach climbs into the chest

over there now if you do endoscopy in these patients and you insufflate

too much before you go in you can actually miss the intertherastic stomach

so usually when we suspect that we use minimal inflation to get into the

stomach through the esophagus, and then only once we insufflate the stomach, and then you

can actually see how the stomach reduces back to the abdominal cavity with the pressure.

I routinely divide the left, the left hepatic arteries, there we are again with the blood

vessels, there we are.

you can see again the white line over there but if i go down you just go down with me now again

we're just going to dissect the sac we start off at the bottom and then we just move up i just want

to just a few landmarks while we are again you can always the first nerve that you see you can

always see the posterior vagal nerve if you open up here it's constant you never miss it and now

Now you can see we're basically just dissecting the sac again.

over there, some adhesions at the top here, I'm just going to divide them, there you can

see the sac again, just going to divide the sac off the right cruz, right.

Now assistance grasper, grasp the sac again there, just pull that out like that for me,

there's tension inside there let's just loosen that a bit continue on the sack slide the usually

when you get to this point that's when the little corner of the stomach is right at the bottom there

you can see we're still just dividing the sack cobwebs over there interesting enough that

additions are always quite flimsy i wonder if they are thick of course makes things much more

Yeah, but I must say they're usually very thin.

It's very seldom to get, you know, very thick adhesions out.

It happens, you know, especially if they've had one or other inflammatory process, yeah?

But you can see we're going down, basically, right down to the V over there at the bottom.

Right, so we've taken the stomach.

And what I'm going to do while we're here, okay, let's just finish this up completely.

I think we're probably through there.

Now we're just going to do the short gastric here to mobilize that area over there.

Loosen that stomach over there.

It's over there as well.

All right, there's our stomach.

Let's just loosen it on the other side.

Take that over there.

You can see the lipoma over there.

Yes, yes.

So the instrumentation that you use, is the common one or you need the same for bariatric surgery, so longer?

I don't use long instruments, just normal instruments, just the normal instruments.

Yes, you can open the drain for sure. Come back a bit, just clean the lens, dry the hang off.

Franz, I think let's just take that over to that side, just keep that one like that for me.

I'm just going to go in there and just see if we can, yeah we definitely need to

loosen the esophagus there. You see that's a lymph node, but we might be so

high already. You see the pulmonary vein going out there? No, sorry we have an

outside view now. Now it's okay, now we're back. Yeah. Say it again. That's inside, there's the pulmonary vein.

Okay. Right, there it goes out. It's not a good idea to cut it. Not even for blood

gases huh right okay right now we've done that now you see once you've dissected the whole sack

let me just demonstrate the sack here as well there's the whole sack okay right now again what

we're going to do is to free the fundus from the sack at the top there like that keep it there and

this is very important if you do these because you otherwise you cannot do a proper fund application

you try and take that stomach around all this fat comes around with it it's terrible it looks

rather loose there's still a big piece of the fatty pad there that'll go to the other side

is that over there as well this huge lipoma is the case to remove or what i normally i just leave it

oh okay i don't take that right okay there we are i think we've mobilized our stomach uh the

The nasogastric tube is just there.

Can we get that into the stomach, please?

You can see there's the tip of the nasogastric tube, eh?

Yeah, I can see clearly.

Yeah.

Just push it forward.

That's coming.

There we are.

That's it.

Fine.

Thank you.

That's good enough.

That's in.

By the way, the nasogastric tube that you use as a guide now,

do you leave it post-op or do you remove it already at the time of the exhibition?

We take it out at the end of the procedure.

So no nasogastric tube in the ward.

Stitch.

Peter, are the hernias big enough or must I get bigger ones for tomorrow?

That's the cases you have collected.

I wonder what's going to happen tomorrow.

What are they doing?

Tomorrow is also giant hernias.

Okay.

These are excellent cases.

Really very good selection.

in your hands, of course.

But these are the problem cases for the surgeons.

Because you'll see every time I've operated a patient,

I do the same procedure, so it's reproducible.

But you often see surgeons,

then they work on this side a little bit,

then they work on that side a little bit,

then they work on this side a little bit,

and then they bleed on this side a little bit.

Then they bleed on the other side a little bit.

And after a while, it's a mess because there's no method.

You must have a standard method that's reproducible when you do these operations.

Yeah, I agree with that, but I mean these difficult operations are so easy in your hands, very easy.

Everything can you do as with the remote control, you know?

Yeah, but I mean these are difficult cases.

You shouldn't underestimate how difficult these can be.

I just want you to take that one like that for me for a minute, see that's the lipoma

in the way there.

Now see when I do this I don't go up, I actually go 45 degrees that side, then I take it at

the top end of the esophagus there, and then again I go 45 degrees to the top over here.

Now this is extremely important not to do a transverse, that doesn't work.

you see it's nice and 45 and this is through a lot of work that we've actually done to try and

get the proper anterior closure and so far I mean you know through the years I've shown different

methods period and this is the one that seems to be the one that works the best with the best long

That initial landmark is very important.

I just want to shift this one a little bit, our liver attractor,

so we can maybe work a bit easier over there.

Again, you must put it on stretch when you put in your suture,

otherwise you end up doing a way too far apart.

You can stop so, Peter.

Peter, how's the quality of the picture on your side?

Absolutely excellent.

Is it? I'm glad.

Absolutely. Really, I was about to tell you, very, very excellent view.

Okay. I remember when we started many years back with the ISDN lines, using four lines to do communication and send it and then you'll see one picture every three seconds.

Now it's really real time.

Yeah.

We are only what, 11,000 k's far?

Yeah, that's not much. By the way, I'm working out my trip to Rome. I'll let you know in the next few days the dates.

Okay, very nice.

I'll be coming that side.

By the way, just now we are relaxed, but any moment in this operation is relaxing for you.

This edition is the 30th, so it was important for Professor Palazzini, which says...

hello to you

and to your team

so it's going to be

a big celebration

so lots of

swigs here

basically tonight

so to him

thank you very much

for inviting us

again

it's always fun

to

to participate

oh yeah

and please

give my regards

to him as well

I will

you can see

I touched

the liver there

with a needle

so it's oozing

a bit

now when you

come

so far

if you go

anterior

you have to be

very careful because you know the pericardium is just there so if you put your stitches too wide

you can actually transverse the pericardium and hit a vessel and cause a pericardial tamponade

which of course could be fatal so you have to be very careful with these high sutures over here

there's always time stay below the vein if you go above the vein it's dangerous territory and

And as I say, you can hit the pericardium.

You can actually strike the heart muscle as well.

It's very thin up there.

Let's come back with the camera a bit.

I'm going to fold that liver back and put it in position.

Nice, Franz.

Just hold that for me there.

Thank you very much.

Is it safe to?

To do a single stitch, a single passage, or rather it's better to have one cross at each time.

Yeah, yeah, yeah.

Well, they're so thick you can't do two at one time, yeah?

But I think the important thing is when you put your suture through the cruci on the left side,

you must pick it up and make sure that you don't hit the aorta,

because it's lying just there, waiting for you.

You must be very respectful of the aorta.

What is also important with these operations is because the crew ray are so weak, you must

always try and keep the peritoneum on them, because if it's nude muscle, the sutures can

tear out quite easy, and you need that strength of the peritoneum to be able to secure a proper

and a good suture.

Oh, that's way too big.

Relax it.

Grasper.

We just take that, we pull back a bit there, from there, we're going to put that stomach over there a bit, roll it over, it's just fat, fat, fat, that's the lipoma.

I want to show you something here, look at the muscle how it's separating, so you must be very careful, you don't pull too hard over there, just relax it a bit, yeah, that's it.

In this case that you have shown just now, because of this stretch of the esophageal muscles,

is there an indication or a thought in the esophagoscopy to look for microperforations or not necessarily?

I've never done that actually, Peter.

And I think a microperforation is probably not a big deal, because that will probably seal off.

Let's have a look at this. This is our stomach fundus, out of the way there, over there,

Good bite through the stomach, off of this.

I just want to show you something again. Come back a bit.

it. Look at this diaphragm. See what's happening. This patient has a pneumothorax. Just look

over there. Now see what's happening as the patient's being ventilated. Look what's happening

with this diaphragm. It's dropping and bulging. That's a pneumothorax. So the patient's intrapulmonary

pressures where in the 20s it's now up to 35 so we're going to just take a

various needle aspirate the nemothorax just take a chest x-ray afterwards to

make sure that it's fully aspirated and that the lung is descended and that's it

but this is often now you see what can you see the ventilation what's happening

yes closing up on the left side you see look at that and that's typical when

when they have a nemothorax if it happens from this side you know it's on the other side sometimes

it happens from both sides right let's have a look and see how big is our hiatus opening over there

i think this is going to be fine yeah that's what i want right now we're going to put in a drain

don't kill it you may want to that in there through the abdominal wall we grab the drain

on the outside and put it back inside. It's the easiest way to get a drain into

the abdomen. I'm just going to stitch this on the outside before we put that

just want to put on the gas again, right, let's just inflate that abdomen a bit.

There we are, our pressures are going up again. Again, here's our sac, I'm going to unfold the sac a

bit over there over there over there over there that sack sit now there easily or no need to

secure with the to anchor with the stitch the sack no it just lies there if you come back it's still

lying there okay fingers all right just check all the ports for bleeding nothing running down here

there we are

congratulations again

I'm tired

going through the literature

I'm aware that there is

I think 4.6%

of conversion rate

what is your feeling about it?

Peter

I think

as you know

I think that's got to do

with experience of the surgeon I cannot remember when last did I convert a

patient for any of these operations as a matter of fact if I can't do it to the

laparoscope I can't do it open so if I convert yeah yeah nothing on that side

I usually listen to hear

yeah it's blowing

right Peter

this is the three cases we have this afternoon

tomorrow we have

four cases and we will

switch over 8 o'clock

on your time

it'll be 9 o'clock in South Africa

it'll be 8 o'clock in Italy

excellent

thanks for your extreme

didactical operations

we've learned lots of tricks

He also thinks of excellent anatomy, clean surgery, quick, what more.

Lisa, is she still there?

Lisa is here.

Nelly is my other assistant.

Nelly, come here.

Okay.

Let me show you.

Come start here.

Good.

These are my two assistants that help me on a day-to-day basis.

Excellent.

Very nice.

So, Peter, you understand I have great difficulty in concentrating on my operations.

And maybe even difficulty in going back home.

Yeah.

Thanks very much. Have a good night. Good rest.

Right.

Thank you to everybody.

Again, Professor Palazzini, thanks very much.

And we'll see you again tomorrow morning.

We'll see you tomorrow morning.

Okay. Bye-bye.

Bye-bye.

Bye-bye.