Dr. VAN DER WALT Hernia

good afternoon hi can you hear me yes fine welcome once again to this excellent congress which is the

34th edition which means a lot of microscopic surgery we in in fact eventually this year again

in presence and the auditorium which is in the south part of rome is full of surgeons besides

the surgeons which are linked on the web.

So welcome on behalf of Professor Palazzini once again

and tell us what we're going to do.

And in fact, I want to tell you that you are always in great shape

together with your assistants.

All right, Piero, good to talk to you again.

I did send you some documents today.

I hope you received them in good order.

Yeah, because I was busy in watching other procedures, you know what I mean?

Yeah, yeah.

At the Congress, but I will recover.

Okay.

Right.

Okay, but it's really good to hear from you again and to join you guys.

We actually had a few cases, and I had a very nice case with achalasia

that we were going to do a helomyotomy on to pay an anti-reflux procedure.

But unfortunately, due to unforeseen circumstances, the patient was canceled.

But we have two others.

The first one we're going to do is a patient who has a hiatus hernia.

Yeah, she actually, it's an elderly lady, she's 71, and the biggest complaint was nocturnal aspiration, and she couldn't sleep anymore.

She had to sit up straight at night.

When she came in, her BMI was 41, and she's lost 22 kilograms in preparation for the surgery, and her BMI is 31 at the moment.

so let's

step up

you can tilt

we're going to tilt the patient

about 20 degrees

and then

slightly towards my side

and then lift the patient

to the roof

I think positioning and ergonomics

are quite important

and I suspect she's going to have

quite a voluminous abdomen

due to the fact that she's lost so much weight right now we're going to place our ports um dj

could you maybe just come to the bottom here but let i yeah okay so yeah can you stand there okay

all right that's it here is the zephyr sternum the rib cage the rib cage the glycus is down here

So our first incision is about 12-13 cm from the top of the confluence of the xiphy sternum

on the edge of the ribcage and we are entering a 5 mm port and insufflating the patient.

This makes the deflation quite quick because as you know the varus needle is quite slow

and the reason why we enter here is of course that this is Palmer's point where

hopefully that's the safest place to enter the abdomen then we check at the

top of the conference of the ribs not at the lower edge of the zephyr sternum but

at the top and there we measure 15 centimeters in midline and that will be

for my camera port which is a 11 millimeter port they're going to place

11 millimeter port over there all right just checking this in and then we're

going to put out in our camera we're not going to switch right now because we're just going to put

in all the other ports as well right there we are right and she's also got a more garden here you

see that yes very clear that's the colon going up over there now second i'll show you now that

our second port is in the circumference of the these two ports then i'm going to put in a port

for the liver retractor i just want to see the size of the liver we'll have a look at that now

that's going to be between the rib cage on the right hand side and that little angle of the

ziffy sternum that'll be our liver retractor then the assistance detector will be over here

between these two ports a bit more lateral we're going to change these ports i'm putting in an

an eight millimeter port over here and then i'm putting that one in there so those are those are

five ports yeah excuse me yes besides the respiratory systems that she can clean off

um any problem with the bowel constipation or so no nothing in the case that the colon

yeah that was all fine yeah no problem now so these are our ports placed now that's the one

in the angle between the zephyr sternum and the ribcage on that side.

This is sort of the mid-clavicular line.

This one's on the edge of the ribs on the left-hand side.

The camera port, 15 millimeters in the midline,

and this working port is between these two ports over here.

Now, if we can switch to the inside picture.

Right.

Now, as we go in, the first thing that we see is this.

All right.

Let's have a look.

let's see what we've got over here that's the colon over there there's the colon transverse

colon that's the momentum coming back one must be very gentle here because often this is very

friable and it can bleed quite easily as you can see there all right just coming colon all right

there we are come on camera right and this is the hernia sec there you can see the pericardium

shining through all right there's our lung radio good yeah okay let's see

this is not going to close up easily

Sure. Big little liver.

And I'll see how it is here.

Okay, what will we do first?

Okay, we're going to start off by fixing the hiatus hernia.

And I think what we're going to do is we're probably going to have to put in a mesh

on that Morgagni hernia because that is very wide

and you can't get it together as you might have seen there.

So here's our hiatus hernia.

So we'll fix this first.

Okay, let's get the nasogastric tube in, please.

I'll pull this straight.

There comes the nasogastric tube.

There it will come.

Okay, just suck on it.

Ah, there, it's already collapsed.

Thank you.

Right.

Okay, we're going to start off by opening the pars flaccida.

You can see the morgogneus.

I don't see any external volumes.

Look at this.

Okay.

There's the diaphragm.

That's the left gastric artery over there.

Pulling this down,

we're just going to start our dissection.

The liver is in the way there.

Let's just get this in underneath there.

That's going to bleed a bit.

Now we're going to have a bit of bleed on the liver there

because this overhanging left lobe

was now touched by the thunderbeet.

Can you sit with your head straight?

Pity?

Can you sit with your head straight, what you wrote down?

Ah, that's better.

Yeah, that's probably going to be a big cumbersome.

Just hit it right there.

That's okay. That'll stop.

Alright, there's the aorta.

Then we're going to continue our dissection

over the anterior part.

That's just to bring the anterior vagus into view.

There we are.

This is a cumbersome little bleed from the liver,

but that will stop in a short while

I'm sure, or not

now we're going to divide the peritoneum

on the cruz

on the left hand side

no adhesions with the pleura

on the left hand side

no, no, with these big hernias

it's very seldom that they actually have

adhesions

well, they're very loose

you can actually loosen them

would you like your dracadals on your lawn?

ok, but you can actually see there

I think

is a there's just fatty tissue over there all right that looks like it's loose right okay

yeah it's bleeding on the from the liver is a bit cumbersome but just eating up the light okay so

now we've actually dissected out the hiatus now what we're going to do is the next step

is to take the short gastrics. Is it always necessary to get rid of the short

gastric? Yes. It is advisable, always? Yeah, always. The thing is if you

don't take them, you pull through the anterior wall of the stomach and then

you actually end up doing a wrap and not a fundoplication because the

So fundoplication is actually inverting the esophagus into the fundus,

and you use the posterior part of the fundus for your pull-through.

So you use a total different piece of stomach,

and I mean we've shown with the Rosetti operation,

they do have more gas bloat, they definitely have more dysphagia,

and we often have to redo Rosetti's to just a standard Nissen,

to get rid of those cumbersome side effects of the operation.

So in my hands, I feel more comfortable taking the short gassics.

And it just takes a few minutes.

It's not a train smash to take them.

There we're dividing them.

And the real reason why you're actually dividing your short gassics

is to free the posterior attachments of the stomach.

There they are.

Because that's what tethers down the posterior fundus.

so that you can't pull through.

So we've taken the short gassics up here,

but this is what you want to divide,

is the posterior attachments.

And that's why you take the short gassics,

is to get to this stage.

This patient has quite a large little hernia here.

I'm just going to divide that onto the cruciate over there.

These fat pads, are they going to stay or are they going to be removed?

I'm not going to take the fat pad out.

The only place where I really would take it out

is with these large intrathoracic stomachs but otherwise if you divide your short gastric

properly it's very seldom or ever necessary to actually remove the fatty pad but in the

intrathoracic stomach it's a bit of a different story because you've got a very large hernia

sac and that hernia sac actually prohibits a proper fundoplication so you usually have to

take out part of the sac with a part of the fatty pad but you'll see over here the fatty pad is not

going to affect us at all and even if they've got a large lipoma here you loosen it and you

just fold it and your your fundoplication must go over around the esophagus proper

right there's our spleen lying here is and we've got an 18 nasogastric tube in the esophagus

so what we've done is to open the right cruz go over keep the anterior vagus there you can see it

and on the posterior side there's our posterior vagus you can see it there it's lying right so

go around take care not to injure your vagus nerves and down right down to the v on the left

side and you'll see during all this dissection I never touched the esophagus

once all the work is around the esophagus and if you do it properly the

esophagus will just fall out and fall into place you don't have to go look for

it and the reason why I also start on the left hand side is that doesn't

matter how large the hernia is the esophagus always lies in a position to

the crux on the right hand side and the larger the hernia the bigger your cavity

on this side and if you go in here especially with a lot of fat like this you don't know where

your esophagus is it can be anywhere in this cavity so you have to go and look for it it's

much easier just finding it straight there when you open it's absolutely over there and when you

open the vagus nerves are also lying there the posterior nerve so you must be very careful if

you cut up over here that you don't cut too deep otherwise you can divide the posterior

vagus nerve right so now and then of course we take the the short gas sticks and we make sure

that we take them right to the bottom so that we can loosen and free you can see the whole

posterior wall of the stomach is now off the posterior because it sits it's tethered over here

and that's usually what holds holds it especially when you do the rosetti operation you don't take

That sort of can cause a kink because of the tension that it can put onto your esophagus.

Right, now we've got our nasogastric tube in position.

And now the next step is we're going to clean our camera and then we're going to start repairing the hiatus.

She is an elderly lady at 71.

So again, the tissue is quite friable.

One must be very gentle and careful with it.

we also deflate the abdomen out you just get rid of all the smoke and the smog

and the steam and whatever there we go and now okay my assistant's going to pick up the

stomach over there for me just waiting for the inflation to go

coming to play again all right okay i'm repeating with a tiger on one which is a nice thick material

so that it doesn't cut into the crurae.

And what I'm going to do at this step is to actually pick up the esophagus

with the nasogastric tube at the top over there.

I'm going to have to put that one in over there like that.

And what that does, it picks up the crurae off the aorta

and it presents the cruci like that.

Then you can quite nicely and quite safely put through your suture

and you can see the aorta is lying at the back there.

If it's lying, if you just leave it like that, it's right on it, and you can hit the water.

Now you can see I'm picking up, I'm putting my needle holder posterior to the esophagus,

and picking up the whole hiatus like that to present the cruciate over there.

The liver is quite large, and you have to take proper big bites of the kuru rei,

and buttress it when you pull through.

otherwise if it's if you take two small bites then uh let's just get this fat out of the way

just gently like that and there's our bottom stitch that's going to be at the bottom of the

cruiser at the v my real safe number enough right and now we're going to suture this

we make our loop to the bottom that one comes from the outside goes through

through and then loop to the top that one goes through like that and then you

slip the knot again to the bottom again to the top oh this is a touchy liver

just touch it that's nice yeah let's just see if we can okay hmm got a

friable fatty liver hey okay now we're keeping esophagus on stretch there so i just put one

stitch posterior and then the rest of the stitches or few stitches i'm going to put anterior to close

up the anterior part of the hiatus and the reason why that is important this is the weeks this is

the weak part of the hiatus it opens to the front it doesn't open to the back so although you can

do your posterior repair you still leave this this weak part over there and i think that's

one of the reasons why we often see so many parasophageal hernias in these cases now the

anterior repair has also got a specific technique if you stitch this from side to side you can't

get the diaphragm together because there's too much tension but this is like a dome of a tent

you can pull it down so what we do is we'll actually take our first suture and try and get

some peritoneum over there get a proper nice bite and that you put a low on the cruise over there

and then you go at about a 60 degree angle to the top and you try and go through that tenderness

part of the diaphragm over there right so you can see it lies 45 to 60 degrees over there

pull that through like that you know i'm just going to go halfway with my suture and i'm going

to make this tail quite long as you can see there right now i'm just going to relax the

liver retractor so that we can pull the diaphragm down i'm going to put the needle in there

put it on stretch and then actually put it up like that otherwise you don't get the right

part of the cruise it folds in and then you don't get a proper closure this is quite an interesting

point because I don't remember to have ever seen this approach from until

here yeah yeah well this is this is what the redo surgery taught me because I was

thinking about that yeah because when you do a lot of redo surgery you start

realizing where the weak spots are and then you start working out ways to

actually get past that weak spot and to compensate for it again you'll see it looks actually quite

close together yeah the redo have been decreased yeah definitely definitely excellent i i i mean

i don't have a double blind randomized study but i've done i've done a few thousand redo so

So, you know, it becomes quite evident in the patients who have multiple recurrences where the problems lie.

Again, a long tail, take it through, slip the knot, put it in there, and pull it together.

So, you actually put your hiatus on stretch.

Because there's no point in putting five stitches posterior.

posterior, because as I say, the weak spot is this flimsy arc, that flimsy arc of the

cruz.

Look how thin it is there.

That's the thing that gives way.

And that's why the hernia just becomes bigger and bigger and bigger.

Not posterior, anterior.

That's where your problem lies.

So if you're going to reinforce it at the back, you've still got this weak spot here.

So what we're trying to do is to create a better arc over there by putting the thick

crew they together anteriorly so I do actually a combination of anterior and

posterior closures I know there was quite a few articles about what is the

best closure anterior or posterior that came out of the Australian literature as

well and it to see that much is very much the same but I think the

combination of the two is actually probably your best this bit so this gap

Yep, must be absolutely, totally obliterated.

Yeah, the weak spot.

What is your feeling or your experience, although this suture is a tagron, which is used by the cardiac surgeon, isn't it?

That's right, yeah, this is a cardiac suture.

Yeah, what about the V-lock for the hiatoplasty?

No, I don't think it's a good idea.

it's uh it's serrated and uh i think it chews through and it knows because it's like a little

sore and if you use it on on soft tissue like this remember we're suturing muscle it's a bit

of a different thing that v-lock actually cuts through the muscle over time so i don't think

it's a good idea to use the v-lock and i've done quite a few actually one of our surgeons here

used the V-Lock for his hiatus repairs,

and he actually then used a continuous suture,

because that's the whole idea of the V-Lock, to do it.

And he actually stopped after about six months

because he saw all those patients coming back

with an alarming rate of recurrences,

and he stopped using the V-Lock at all.

I haven't used the V-Lock myself,

but personally I don't think, well, based on his experience as well,

that it's a good idea to try and suture a muscle with V-lock.

But that's my feeling.

You know, I mean, I'm sure there's other people that have other ideas,

but I think it's quite logic that you shouldn't use something like that.

And also the other thing is using a continuous suture on the crudé.

in the early days

when we could not well

we did that as well

and we saw that that's not a good idea

they also tend to

fall apart over time

there we are

and what about

your feeling for

the use of

prosthesis

I think you should be put in jail

if you do that

it's criminal

alright

Yeah. You know, I have seen so many complications of meshes where the patient ends up with an Ivor Lewis esophageal gastectomy due to erosion of the mesh.

And, you know, if you look back, these patients, I mean, they're cripples then for the rest of their lives.

and

now if you go and look at the pathology

I mean we're not operating a cancer

we're operating a symptom

the symptom is heartburn

now if you have heartburn and you end up

with a esophageal

gastrectomy as a

complication of the surgery

that you got then I think

I'm afraid I think we're doing something wrong

because that is

that's still very large

because to end up with that

That type of complication and that type of surgery for a symptom of heartburn, I think one must think twice.

I've also, I did, you know, in the middle of 2000s, I did a lot of meshes.

Well, not lots, but I mean, we basically, we never used them in primary, but we often in these large hernias used them.

And I very quickly stopped.

Well, very quickly, I probably put in a little bit more than 100 meshes.

but I can tell you I stopped

because of all the complications and erosions

that I saw

if you scope the patient a year or two down the line

and the mesh is eroding into

his esophagus, I mean that is

a disaster, that's really

a disaster

so I'm not fond of mesh and the biological meshes

don't work at all

if you come back, biological mesh

I think all that does is just give

macrophages a nice party

because they come and eat it up and if you come back after a year or two

when they recur

because they do recur

as we've also seen

with the incisional hernias

it just doesn't work

the recurrence rate

is exactly the same

whether you don't use a mesh

I mean that's been shown

very clearly

in the literature as well

if you come back here

and you've put that mesh

because we usually

tack them with a few

little tackers here

or even if you suture them

if you come back

all you find is your tacks

and there is no mesh

it's gone

so to use a

a biological mesh they're expensive and they just don't work so there's no point in using

a biologic biological mesh now we've closed up the the hiatus and i'll show you it does look a

bit tight at this stage usually what i do is i leave it to be open a centimeter so it's the

nasogastric tubing the esophagus one hold it one instrument over there it's a five millimeter

instrument, and another 5

instrument, that gives us a 1 cm

little gap over here.

And that's how I size it.

Alright. Alright, what we're

going to do now, is I just want to clean up

this bit of blood that

we've got here as well.

Here's your measure.

X-cell composite measure.

10 by 15.

That was not very well spoken.

Ah, this liver is really

a nuisance. Okay.

So what I'm going to do now, is

to do take my piece of stomach through so what we're doing here is just to tuck in that fundus

over there and then roll this esophagus over like that and the fundus actually presents itself over

there and there you can see these are the short gas sticks that we took this is the hernia sec

as you can see that's the fatty pad there's our biggest line this will pull us through a bit

so we have

we've got our stomach

let's pull

pull through there

take that one

over there

and I want to

if I keep them together

I must be able

to fit

an extra esophagus

here

or another way

of measuring it

is that one

over there

and that one

over there

you must have

a complete overlap

of the width

of the esophagus

that's the minimum

if you make it

more than that

the nisant

can actually

urinate through itself and if you make it less that's going to be too tight but i think the

most important thing is once you've done your mobilization the stomach must just lie there

and that stomach must lie there you must be able to get it together very easily like that

no tension whatsoever there's where we took it oh you can see how easily the stomach bruises over

over here. It's really got very

soft tissue. The stitch

is the same for the iatoplasty?

Yeah, there. Stitch.

Same stitch. I only

use one stitch for the whole operation.

Here's the vagus, and you

can see these little veins here.

See them there? Those transverse veins?

Yes. There they are.

That is the Z-line. That's how

I identify the Z-line on the outside.

It's not written in any anatomy book.

And that is

in fact an excellent landmark,

Mark, not to put

the stomach too low

which is going to have an immediate

recurrence.

Absolutely. Now we take our stitch

through this side. Right, now we're

going to tie this, take

my loop, take that one,

pull it through, and then I'm going to

put it down and I keep it there so that that one

can't run away. Grab it like this.

Oh, it's blue.

I think once we drop the liver

and the

congestion of the liver is better,

then the bleeding will stop

immediately

and you can see all the other fatty paddies over here

we're actually putting our fun application

around the esophagus

nice big bite through the stomach

otherwise it tears out

with the first cough

I'll use a little hard track

because I've used up the whole

suture

what is the reason also to pass this stitch

which, although superficial,

through the anterior wall of the esophagus.

Through the?

Anterior wall of the esophagus.

It's to fix that rep so that it doesn't slip down.

Okay.

Because if you just put it around the esophagus,

the esophagus, especially if it's slightly short,

pulls back,

and it actually pulls all this in through the nissen.

And then you end up with a slipped nissen.

So you must,

I feel very serious that you should fixate.

And as I say, I actually use the anterior vagus.

I put it through underneath the anterior vagus to make sure that it stays in position.

And, you know, even with doing that, I've never seen any problems with any post-vagotomy symptoms if you use the anterior vagus like that.

As a matter of fact, quite the contrary, the important vagus as far as that is concerned is the posterior vagus.

If you injure your posterior vagus, you get much more post or, you know,

you're bound to get some post-vagotomy symptoms.

So there's our line.

So we pick it up and we check again.

That's one centimeter behind the esophagus.

And you can see to close up this itis, we used four sutures anteriorly, two posterior.

That's a total of six stitches to close up the diaphragm.

we're just going to drop this liver so that the congestion

can just, you've got quite a big fat

liver as you can see

I think while this is

just taking off the congestion then that'll stop

just one comment in case

for the anti-slippery

stitch, meaning the

Rossetti stitch

sorry, beg your pardon, just repeat that please Piero

I was wondering

to put

an anti-slippery stitch

stomach to stomach

the Rossetti stitch

basically. That doesn't

help at all.

It still slips through. You have

to fix it on the esophagus.

I know exactly the

resente stitch you're talking about, but

that doesn't prevent slippage.

That doesn't prevent slippage.

But listen,

it's a real superficial

so it's only the muscular

part of the esophagus.

This stitch...

No, I go through the muscle part

of the stitches you don't want to perforate the esophagus go to the mucosa but the thing that i

use that strong is the anterior vagus because that's actually the thing that keeps it in

position i use that as a pleasure all right now it's a big question how we're going to close up

this all right yeah okay almost all the inate okay if you have my clips but this is a congenital

yeah

congenital

murgagni

earlier

but in fact

what was

giving problems

to this lady

was the

ayat

ayat

not the

murgagni

this was

asymptomatic

right

right let's see

have you got a

composite mesh

I just quickly

want to choose a mesh

because I have to

close up at all

right

right

yeah

Yeah, I'm just trying to get a mesh to put, this is a place where you have to cause, you

can't close this with sutures, it's, we can maybe just deflate the abdomen and see how

far we can get there with that, if we close up, oh, we might be able to close it up, oh,

Oh, no, we can maybe get this up there because you want to switch it onto the sternum there.

All right.

Okay, let's go.

Let's give it a go, Joe.

Okay, Stitches.

Can you just set the pressure?

What does the other means?

What does Ruth say?

This way.

Thank you.

All right.

Okay, Stitch.

Yeah.

Can you for us to stick him?

Wait, please, Petty.

I've deflated the abdomen quite a bit now.

Now, in anticipation to try and close this hole, let's see what we can do.

This might be a bit of a difficult suturing thing.

The abdomen is now very flat.

Releasing this string won't help you?

Releasing?

This string at six hours now.

That one there?

Yeah.

I think that's so loose it doesn't see.

I don't think that makes a difference.

Look at, it's very loose.

Okay.

No tension there.

Okay.

Okay.

Okay.

I can just put a little bit of pressure on your machine and set it to 6.

Just want to inflate the abdomen a little bit.

Yeah, because there's no pressure now.

Yes, take it down to 6.

All right, so our pressure in the abdomen is now just 6 millimeters.

I'm going to melt it all the way around.

Okay, let's see.

30 minutes.

Okay.

I'm not going to do a lot of pain.

No, loose, loose.

Yes, Piero. How is the weather in Rome at the moment?

Well, it is not cold at all. It was a bit windy yesterday and it's cloudy.

But overall, at the end of November, winter is not here.

Apparently, the cold should arrive Sunday.

Okay.

So you can still pop to the seaside, you know.

Yeah. It's now as hot in South Africa as when we were in Rome.

in June

it's 35, 38 degrees

some places yesterday

it was 42

so I was thinking of you

while I was lying in the pool having some wine

yesterday

so I thought there you are

nice dressed up

all cozy

thanks very much, I appreciate it

that's quite challenging

to suture upside down

the challenge is also

So, because you face

suddenly this situation, I believe.

Yeah, you're right.

You're almost there.

Yeah, I think we're going to close it without a mesh.

So, you must catch the

substance of

the diaphragm. Yeah, the edge.

Yes, of course.

I mean, yeah, I'll try to take

a deep stitch

against the sternum.

Because if you can

catch a bit of the perichondrium, that's also a good

idea and we're working in it with a pressure in the abdomen now of six millimeters mercury

basically yeah so it's uh deflated quite a bit but uh with because if you keep it fully inflated

you'll never get this together yeah in fact this has allowed you to approximate that's it edges ah

Beautiful, beautiful, very nice.

The cavity that is left behind now is going to give any problem to the patient?

No, it looks like CO2, it absorbs very quickly.

Okay.

If you take it, do an X-ray tomorrow, it's gone.

All right, all right.

it in fact it was and i realized it was even safer to to leave this string because it helps you yeah

Gagni we're doing this year.

I just had a few of them.

no just state morgani yeah they actually came from the pulmonologists uh where they were

you know seen on the x-rays all right and uh but they're usually asymptomatic

buongiorno piero marco barbieri da reggio emilia ciao ciao marco come stai volevo l'occasione per

salutarti grazie posso fare qualche domanda dottor van der walt assolutamente che certo

certo in inglese ovviamente professor yes professor good morning marco barbieri

from reggio emilia hello marco congratulations for your procedure i i have a couple of questions

the stitches you're you're putting is of ptfe goretex no no this is uh

uh it's the same as if you bond yeah okay yeah yeah i used to use um if you bond

I found Gore-Tex in the olden days, but the problem with the Gore-Tex, of course, except that it's expensive, is it's very slippery.

So you really have to make a lot of knots to make sure that it's secure.

And I used to use the same thickness Gore-Tex, the one, the CVO, or the cardiovascular suture.

And that works quite well.

And when we used it, it was the early days when our camera systems weren't very good.

And the lighting was, you know, it was easier to see the white stitch.

Okay, okay.

Understand.

Now, of course, it wasn't political here in South Africa.

We actually made a joke about it once.

you know the whole world is now so sensitive if you make any joke

somebody's going to be offended you know but as i say offense is taken it's not given

but but but when the one chip cameras were out we used to use the the vortex i think i'm still

going to put one stitch there and uh they just made it easier but for sure i mean in the beginning

we used to make at least uh six or nine knots for vortex to uh to last okay and uh that's actually

one of the reasons i changed over to to the dichron uh it just gives a much more secure knot

okay the second question is are you waiting for a mesh or i missed something oh no no no

Mesh, no mesh, zero mesh.

No mesh?

Against mesh.

Yeah, yeah.

Against mesh.

Mesh, yeah.

Mesh should be used in a window for mosquitoes, that's all.

Okay.

Have you heard, Marco?

Before I understood that he was waiting for the prosthesis.

No, because this person, this patient, has a double problem.

the herniated hernia that he made in the system and this one that he calls morgani and this is the hernia of morgani

and the gap was quite large so initially he thought of putting a network then

wait wait then he thought of this in an extraordinary way because to reduce that

the gap you have not seen it but in short it was a gap no I have not seen it before it is a bit that I follow you

I tell you that the system that has been adopted practically has significantly reduced the first

peritoneum that is it is with 6 mm in which this has allowed it to approach the gap to make it

smaller sorry and therefore to be able to put these points of tycron which are the same that it puts

when he did the hiatoglastic

sorry Ein

it was quick to talk in Italian

to Marco

of course I understand everything

of course

I've tried

to explain

your next surgery

yeah

but I also

heard you explain

my aversion to mesh

to him

one more thing

this procedure

I'm not talking about the Morgania

yes

I'm talking about the straightforward Ayatozenia

whatever size whatever it is

what about

doing this robotic

any advantage

or what

no I don't think there's any advantage

I think the advantage is

if you're not a good laparoscopic surgery

and you don't have a proper coordination

I think it's a very good tool

for you to use and I think it will give inexperienced surgeons the ability to do some surgeries

that they probably won't do with ordinary laparoscopy. But I think you will very seldom

find an expert laparoscopic surgeon going back to the robot. The robot has got important

places especially with the urologist where they work in a 3D environment. They don't

have a gallbladder to practice in a 2d situation like we as surgeons do so in that case you know

that helps them a lot because again it's natural hand movements being transmitted by the robot you

know it's like cutting keys on this side you've got a little machine and on that side it's cutting

the key so it's just a replication of what you're doing with your hands so it has got a place but i

I don't think there's any specifically, you know, in gallbladder, upper GI surgery,

I don't think there's any big advantage of using a robot.

I think that with the prostates and stuff like that, I think it's good.

With the very low anterior resections, I think it's excellent to get into the pelvis.

And for pelvic repair surgery, I think it's wonderful.

But where you've got a lot of space and you can work with a laparoscope,

I think that will be the preferred method.

I know the big hype at the moment is, of course, robotics and artificial intelligence.

So maybe one of these days we can just send the patient to theater, sit in the office,

and let artificial intelligence put in the ports, insufflate the patient, do the surgery,

and might as well just do the ward rounds as well afterwards, you know,

so we don't have any jobs any one of these days.

So it's a big hype at the moment, and I think it's just probably a bit over-exaggerated

as to how artificial intelligence is going to take over the world

and take over medicine.

You'll still need that human fact and that human touch.

Fair enough.

Thanks very much.

Thanks a lot.

Right.

Piero, we are finished with this case now.

We're going to – we've just got one thing to do now.

So I think we're going to give it a 20-minute break.

20-minute break, then we'll be online again.

Okay, thanks.

See you very soon.

Thanks.

thank you very much beautiful nice to meet you marco ciao ciao ciao see you later right