Heine van der Walt Laparoscopic repair of a large hiatus hernia

Right, Piro, we are at our patient now.

This is a female patient.

I'm just going to go through the port placements like we normally do them.

Our first entry is going to be about 12 to 15 centimeters from the top of the zephyr sternum.

Pull the skin down on the ribcage, small incision, and we use an optic trocar without the camera.

We are.

You can see it here.

I see it first.

is the patient supine or

in

yeah supine and I'm

standing on the left hand side of the patient

there's a big

if you suck

that's okay

don't get beginning my country

it's a tits okay donkey

right then from the top

of the ziffy sternum with a

ribs get together not from the bottom of

the ziffy of the top of the

ziffy 15 centimeters

meters in the midline, that's my camera port, and that'll be a 10 millimeter port, there we are,

right, yeah, okay, fine, now our next port is going to be between these two ports over here,

that's going to be a five millimeter, patient is quite a large liver,

We have two other 5mm ports, one between the ziffy and the ribs, the rib cage on the right

hand side, and one sort of mid-rectus on the right hand side.

And then we replace the 5mm here with an 8mm, and the reason why I use an 8mm is that's

the smallest trocar through which a 26mm needle can go.

So, right, so that's basically our port placement.

8mm, about 12cm from the top of the zephyr sternum.

Camera port, 15cm in the midline.

5mm between these two ports.

5mm just lateral to the zephyr sternum.

And then our little lateral port over there.

And now we're going to go in with our instruments.

First the 5mm to pick up the tip of the liver.

Then the liver retracted to pick up the liver.

And there you can see the...

The hole in the diaphragm, as you can see, the hiatus, quite a large hernia.

So I'll press it a little harder.

It's really big in the liver.

Right, now the left hand is the grasper.

Right hand is the thunderbeat.

We're going to divide the pars flaccida first.

First, with a lesser momentum.

Now, Peter, can you just turn it a little bit over?

Thank you.

Perfect.

Turn it a little bit up.

Okay, thank you.

And dim the light a little bit.

All right, now we grab the medial edge.

There's our white line coming down there.

Going to open up the peritoneum.

You always go and look for the esophagus on the right-hand side of the patient

because it's always in a position to the cruz.

on this side you've got no idea where the esophagus is so you media immediately have

your landmarks the first thing that we're going to do is to open this up

right down to the bottom there you can see the sub diaphragmatic artery going

shift this up a bit create a space posterior there you can see the reflection of the peritoneum

on the aorta over there now we're going to continue our incision over here

And with these large hernias, you can usually quite easily coax the esophagus loose.

You'll see we do not actually try and reduce the stomach.

We actually keep it in the inner hernia sac.

You want it there, otherwise it's just in the way.

There we are.

Leave about one centimeter of peritoneum there, of the sac.

Again, loosening, stripping the esophagus away.

Oh yeah, we'll show you all the vagus and everything just now. Dividing the sac

again. There's the anterior vagus nerve. So we keep the stomach inside the sac.

Just stay there all the time. Let's see. Again dividing the sac. Just coaxing away

the esophagus and the sac. Loosen those adhesions. There's the edge of the

the diaphragm. Keep that over there. Pull this out through like that. And pick it up

with the left hand over there. There you can see the adhesions, blood vessels going to

the esophagus. Yeah, I'll show you now. Right, again there you can see the anterior vagus

nerve lying over there. If we look over here, this is the pleura right on the lateral side.

it's pushed away completely because of such a large hernia so we're just loosening that over

there there's the aorta you see it lying over there quite a good idea not to cut it off to do

blood gases maybe yeah right we're loosening this now you can see the stomach is coming into

into play over here there is the in this case i don't think we call them the short gastrics we

We call them the long gastrics because they're so stretched out.

Again, dividing right down to the diaphragm over there.

This one, the hemostasis there.

And there you can see in the V of the cruderae of the diaphragm.

We'll open this from the other side.

There's our short gastrics.

Now, let's just go to the other side.

We've actually already created our window.

There it is.

Just going to divide this tissue over here.

and you can see all the dissection

we're just going to loosen the esophagus there

that we've done

we haven't touched the esophagus

we've just actually dissected the curure

and what happens is

the esophagus comes into view

by itself

you never have to look for the esophagus

you just do your dissection around

and it'll come out

now there's our ronea sac

and you see we never actually

reduce the stomach

stomach. Now the stomach is reduced by itself. Right, now we're just going to take the short

gastrics, start off there. That's from the pressure on the lower lobes of the lung, right,

because there's such a big, see that's already loose there.

And did the patient have respiratory problem because I didn't catch it?

Yeah. Well, no, she didn't have any lung problems. Now you can see we've actually loosened that over there. There's the hernia sac. And now you can see the hernia sac is actually stuck to this part of the fundus as well.

Now, if you don't loosen this, you can't get the proper fundoplication because the sac is in the way.

So, what we're going to do now is over here on the lateral side, the left lateral side, we're going to loosen the sac.

You don't have to remove the sac.

That's not necessary.

But you have to loosen the sac right up to the esophagus.

And the reason for that is so that you can swing your stomach around and get a proper fundoplication.

right so we just about down to the esophagus over there come here there we

are right and here's your old sack you can remove the sack if you want to but

as you can see it's a big sack for a lot of unnecessary dissection it's not

necessary all right so there's the actually the let me just check the

nasogastric tube is in position no it's not there you get there's the tip of the

the nasogastric tube. So we're going to push the nasogastric tube in. There we are. It's

coming. Push, push. Will it be the NG tube enough to calibrate? Otherwise, is it necessary

to put a bougie? No. I use an 18 French. Here's the spleen tip. I use an 18 French nasogastric

tube but that's that's too thin i use that plus one centimeter at the back and i'll demonstrate

that as we go along we're just going to keep it just going to clean the camera and de-smoke the

abdomen so that basically takes care of the dissection of the esophagus and the stomach

simple little things but quite important right now we've got a better view again we're going to

start off by closing up the diaphragm stitch I use a tiger on one on a 26

millimeter needle it's a cardiovascular suture now one way you can actually

present your fundus is to pick up the esophagus and that brings out your

fundus otherwise you risk going through the aorta over there right now I'll

demonstrate the knotting technique nice and slowly you take your loop of thread with pronation of the

needle holder to make a loop to the bottom that one just comes from the outside and to the bottom

there as well so from the outside to the bottom take that pull it back through and then you

supinate make a loop to the top again that just comes from the side and it goes through the top

and there we have a perfect square knot and now by relaxing the right hand and pulling the left end

you capsize your knot and you tighten it up pull back slightly on the short one and that locks the

knot there we are you got that peter excellent very clear the next note we put the first knot

so that we just line up the crud and now I'm just going to here you can see the

anterior vagus a bit on tension often if these large areas if you can't get down

the esophagus far enough you have to cut that nerve sometimes both of them right

now what we're going to do is to pick up this and see towards more or less there

is there the top of the esophagus we're going to go through there and you can

can see I'm stretching this out sort of like 45 degrees again there and now we're taking that over

there so this switch is lying at about 60 degrees as you can see right now what I'm going to do

is I'm going to pull this through you see this tail is very long I'll show you now why again

the same technique taking right at the end there now I'm going to relax the liver retractor

if I can.

Putting tension over there.

Putting this out and getting them up there.

Putting back on that one a bit.

On the arm.

Scare.

Hold foot forward.

Right, let's just pick this up again a bit.

Just replace that

liver retractor.

But you have to relax

the diaphragm

to be able to pull it down.

Because as I explained with one of our

previous things, you can't pull it

from horizontally from side to side but because the diaphragm is a dome you can pull it down

and you can close very large hiatuses without the use of any prosthetic material

which i think should just about plus minus be used only once in 100 years and only once

and then in that case you can probably start practicing how to do esophageal gastrectomy

me because that's where they end if that mesh undergoes complications is there any space to

tilt the left lobe of the liver if there is there is there any possibility or under chance

to tilt the left lobe of the liver instead of the retractor i mean does it help you more or not

or is enough with the liver retractor the liver retractors is enough i don't think it's necessary

for mobilization or anything like that if it's a very large liver i mean as you can see i use a rod

and the reason i use a rod is i work in a tent now but sometimes when the liver is very large

then i would put in a fan retractor just under the right rib edge quite laterally on the abdomen

and bring it in from this side to pick up the liver like that this patient actually had a very

large liver and she was now on a diet and the liver reducing diet for the

last six months and she had a enormous liver and we first had to shrink the

liver before we could bring her in for surgery I think it's probably a Chianti

liver yeah even the color looks like

Right.

Sure.

A bit bigger, I think.

Another way you can put in the stitch is to bring that and put the needle in reverse.

And then just take your stitch through like that.

Also an easy way to get that needle through there.

I don't know why you're nervous.

There we go.

I feel so great.

I still can't sit.

Okay.

That doesn't want to go in.

Right.

so that's the anterior part of the of the itis that we've closed now we're

going to bring the esophagus back into position that's one over there we're

just going to reset our liver attractor so that we can work on this side again

Now this is quite a big aietis.

Normally we use just one thread, but with this large aietis, obviously we're going to

use more than one suture.

Because remember, there's no traction on the esophagus at the moment.

Right, now we're going to do the fundoplication.

Take that out of the way.

Take that top part there and push it in nicely.

Washing in direct.

The space that you leave at the crura,

it is enough to put inside the instruments.

That's how you calibrate.

Yeah.

I'll show you now when we're finished how I measure to make sure that it's right.

And that equates to about a bougie of about 48, 50.

If I ask my mark over here.

Pull down on that esophagus a bit.

Okay.

Just grab it again.

All right.

So there's the esophagus proper.

We don't want to put it around here.

That's too low.

There's our, you can see there's where the short gas six were taken.

It lies there by itself.

No tension.

We do our sunshine.

We make sure we've got a complete overlap.

lap or you can put in another esophagus over there then you know that's not too tight now what i do

here is i actually use the anterior vagus as a bit of a pledged to make sure that that nissen

funnel application won't slip off grab that and then i put it down there so that i keep that

thread there, otherwise it swings around

everywhere.

This is a sliding

hernia

with an excellent technique.

In case of a yaduzhenya

due to brachiosophagus,

would it be possible

to do the same?

Or what do you suggest?

Well, the brachiosophagus,

you know, what I would do then is

I would do a very high dissection

right up to behind the carina.

to make sure that I get enough lymph in the esophagus.

I don't do colisnessins anymore.

They just present with other problems later,

either stenosis or they make a sort of a pouch at the top there.

It's a peristaltic segment.

They have dysphagia, sometimes even food retention in the esophagus,

and they're not happy people.

So I don't do a colisnessin anymore.

more so if i have a brachial esophagus i will operate the patient bring it down as far as i can

do a nissen and fixate it and keep it there and then i'll give the patient one year

because what happens is that esophagus becomes softer it becomes more pliable and then come

back after one year and then you can often win another five six centimeters on the esophagus

again and they'll do a second procedure to to get that esophagus down now you'll see

there's our nasa now let's go and have a look at the space behind what i want there is at least

two five millimeter instruments because i want to have a centimeter over there and now you can

see that's a five millimeter instrument another five so that gives me one centimeter plus a 18

nasogastric tube in the esophagus and that's the space that i would have this one's maybe

slightly closed but especially with these larger areas you must close them a little bit more

snuggly otherwise they tend to go back and pull up and recur but that's fine that's 100 good and

then we drop the liver we put in local anesthetic two grams of markane with two uh two ampules

of one ampule 20 milliliters of markane with two grams of magnesium sulfate now i take out

my ports we check for any bleeding running down that looks fine the older you get the faster you

are i was going slow today peter to show and demonstrate nicely i don't know whether i must

be worried you know for your speed right that's our first case our next case is going to be a

a Gastic Bypass

as we do it.

Right, so we'll speak to you

in a short while again.

Alright, so what, 15 minutes or so?

Or what? 20 minutes or so?

10-15 minutes.

Give us 15 minutes. That's fine.

Okay. Thanks very much.

Speak to you soon.

Thank you.