Prof. Heine van der Walt

Is Piero aan die ander kant?

Ja, we here.

Ok, right, Piero.

Ready to watch you once again.

Heltfons, voet af.

Dankie, stop.

Jy my kant toe.

Stop.

Tel op.

Staan weg.

So bykie terugtelt.

Net so titselkie.

Stop.

Ah, sê.

Right, we're going to use the same port areas.

This patient has had previous surgeries elsewhere.

sy het ook een tuinje gehad en veel plasticieke oorlog ook en dit kan soms

die abdement best toon, so dat dit best plat is en vaak tende die patiënt ook te

het een beetje een groot liever, speciaal as hulle besmaak het, ek het die abdement inflate

tot 15 mm mercury, dit gaan best snel met die 5 mm port, nie so laag

as with the varus needle.

Varus needle takes 4 minutes.

This one takes about 40 seconds.

O ja, dat tielik.

Alright, 15 centimeters

in the midline.

That's our camera port.

Sorry, Aine, what's about

this case?

This patient had surgery

in 2018

at another hospital

and she came in

with recurrent

symptoms

with heartburn, reflux, chest pain

just about everything, worse than

before

and I can eat with change

then

on evaluation

she had a total breakdown of the previous

nissen, the hiatus was wide open

and the nissen was

actually done very low

around the

stomach, now it's important

to, when you have a patient with

failure to distinguish what the reason for the failure is the previous patients obviously it's

a patient failure with diaphragmatic failure but sometimes you have surgeon failure that the

technique of the operation was not right the position of the rep wasn't properly or that the

diaphragm wasn't sutured up properly now that's what we're going to determine yeah yeah we're

going to pick up right she has a few adhesions that we'll be taking down yes let's get our liver

retrakteer in positie, nou, dit is klaar, ok, dit is heel mooi, heel weinig lesions, maar

in ieder geval, die punt wat ek net gaan maak, is dat jy tussen een patiënt verkeer of

surgical verkeer moet distingueer, surgical verkeer is waar die techniek verkeerd was en die operasie

verkeerd was, nou, vaak as jy net die operasie doen, verkeer hulle, hulle vind as dit patiënt verkeer is

with a weak diaphragm here you can see the vena cava very close approximation to the cruise there

if you have a surgical failure then that's usually easy to remedy the problem is

the one that recurs all right let's see we saw what's a plaster well okay

Ok, hier gaan we een beetje meer posteriër gaan starten, om oop te open te hou van die vandes van die lichaam, dit is alweer een goeie manier om hierdie casus te aansluit.

Ek wil nie vir die Wienerkever gaan, dit is vir die Wienerkever daar, ek wil nie vir dit af.

Ok, dit is die hele trik van die syrge, dit is om te probeer om jou plane te vind, wat ons nou probeer en ek dink dat ons dit daar gevond het.

over there. Alright, let's see what

carving the stomach out

of this hiatus at the moment.

You see it's a bit bloody.

That's sometimes to be expected.

Good sign that the patient still got

circulation. Yeah,

bright red.

Well, it's quite challenging

to find the exact

layers here. Oh yeah,

Ja, dit kan heel moeilik wees,

speciaal as dit gefused is,

jy weet nie, jy kan jou planeet nie so makkig vind.

Nou, dit is nie te baie, maar,

dit kon wees.

Ja, kan jy ons ook vertel,

vertel ons, die landmaat,

die anatomieke landmaat, wat

wat jy, wat jy aan het doen,

Right, nou, op dit moment, we probeer ons net

om die lichaam, ja?

Ja, ek wil net sê, ah, daar is

die klein blieder,

over hier,

there we are,

right, we try to identify the crew ray as

well as we can,

and this looks like the fatty pad,

but I still don't know how they go,

right, let's go over to that side,

you can see we're actually pulling

the fundus of the stomach

is in there,

and you can see now, it's coming out,

it's coming out,

coming out,

So jy sê die patiënt het een groot parasofagelene over hier.

Ek identifieer die kruis op die kant.

Daar is die.

En oor die situasie, ek word nie verbaasd

oor die symptoom wat hy vir jou referteer.

Ja, ja, ek weet nie.

Dit is ongelooflik, vir jou.

Ja, hy het een groot, groot parasofagelene.

Op die skope, half van die stommel was in die kist.

In jouw praktiek, Ayn, het nie oor die strangulatie van die hernia gebeur?

Ja, ja, ja.

En die oorlogse gastrectomie?

Ja, ek het een aantal gangrense stommies gehaald,

die oorlogse gastrectomie,

want hulle soms ook perforeer,

aswel. So what would often

happen is that you'd actually do them

and just do

a esophagostomy and

your roo-lai-waai-lim

you just leave and then come back

a bit later once the sepsis is cleared up.

Especially if they had perforation.

But

often you can

just primarily

do a roo-lai-waai-lim

up to the esophagus

because they usually

jy het, die oesophagus is nogal weesbaar en tuurlijk kan jy dan jou rooie loop doen,

ja, we ontwikkelde die ruimte wat die oesophagus in die oesophagus is, dit is die oesophagus

daarboven, dit is nie ongemoedig om een neemothorexie te ontwikkelde aswel,

want vaak is die pleura absoluut verstaan en gefused met die oesophagus en net om jy te

everything oh there we've got a pneumothorax can you see that's the pleura opening there

there's the vagus nerve i'm gonna cut you see it's stuck to the pleura

dan het dit het al, het nie

om te spreek,

we al het ons probleem in

lewe,

my is

is to get the operation done

yours is being married

the nephritis must

deal with the pneumothorax

now we just need to

tell them so that they know and they'll do some

volume loading, sometimes they actually have to put them on

to inotropes just to help to get

that blood pressure up and it would

sometimes happen that you actually have to stop

the operation for a little while

put the patient flap, catch up with the blood

pressure again and then continue

but my nephritis has got nerves of

steel, they've been

geleid en getraind in die manier so dat ek in vrede kan operere. Ja, ja, maar dit is niets nie

gegeven, jy weet nie, absoluut nie. Ja, dit is veel slechter, dit is veel slechter.

Ondersteun, maar dan later, hoe kom jy weg met die motorek, met die tube of net in jouw

techniek? Nee, we, net, net, ja, ja, want, kijk, er is nie, er is nie licht op die lung

hetsel, so jy moet nie in die tube doen, we doen net een aspiratie met een verus

needle so that you don't puncture the lungs afterwards do a chest x-ray in the recovery room

and if it's fine that's fine you would very seldom get a persistent pneumothorax that needs a

second aspiration which we'll then do there you can see the vagus nerve again and then we'll do that

right okay i just want to loosen the esophagus on this side because that scar tissue is keeping

die esophagus en in die geval moet jy een proper hoge mobilisering doen om te bewaar

dat jy genoeg esophagus neergeweer om te bewaar om die esophagus proper te draai omhoog te draai

want ons verwacht dat dit patiënt ook wat van die korte esophagus

aswel moet het, want die e.g. junksie was 32 cm ja en hoe besluit jy om

to stop pulling down

these halfagose.

Well, usually if I've got enough, if I don't have

enough, then I'll just

try and fixate it where we can,

do this

operation, and

then wait until this

everything settles,

and sometimes do a second

operation a year or two later.

Now you can see,

this is where the nissen comes around.

Right, now let's look at this

carefully.

Hier is die nissen, hier is die fattie pad, so dit nissen was gedaan oor die stem, hier is die esophagus, so dit is die surgical failure, dit is die incorrect placement van die wrap, en dit, as ek het gezegd, is het belangrijk om te distingueer between a surgical failure and a patient failure.

This is a surgical failure.

In other words, the operation was done incorrectly right from the start.

And if you listen to the patient's history,

she also didn't have much relief of her symptoms

and she's actually been on PPIs ever since the operation.

So she never had a proper operation done.

So what we're going to do now is to take down this operation,

so-called Nissen,

but this is not what Nissen described

personal variation

yeah

yeah

as the bureau 3

this must be Nissen 2

yeah

but can you see, there is the fundus

there is the fundus, look where this

this is the corpus of the stomach

ridiculous

good afternoon, I'm Marco Freschi

good afternoon

I'm here close to Piero

because I'm a partner

van die Vandervaart Internationale

Fellowship

en Fan

Club.

It seems the

stomach was around itself.

The stomach is around itself,

absolutely, yes.

Like the previous,

like last year, we have

seen a similar

case, I remember.

Yeah,

this ends up with a cascaded

stomach of wat jy, of soms jy dit

ouweglas stomach noem, waar jy jou

stomach in 2 kompartements het. Ja, ja, ja, en

sien, en ook, uh, want, uh, die

soergen het nie isoleer, nie

immobiliseer die, die, die esophagus,

verhaal. Ja, ja, en ek dink as

we op die esophagus gaan om die

rap just nou, jy sal sê dat

daar is heel weinig

soergerie gedaan, maar ek dink nie

dit esophagus was

eindelijk ooit getoucht. En een

Ek kan hier niek systeem sê.

Ja, ek sê ek het hier nie systeem sê.

Ja, ja, ja.

Misschien het hy hier wat kleur gebruik.

Ja, haha.

Ek dink hy gebruik kromit.

Plenum kromit.

Dit is die juiste kies.

Die juiste kies.

Now I'm going to swing that around, pull the fundus out on this side and see that we can

free it as much as we can. Just going to take my systems grasper, hold it over there,

Okay, Lisa, Kiki, I think we need to take these short gas sticks here as well.

I think that sooner or later, this woman would have had serious vascular problems.

Yeah, she would have ended up with a volvulus and an intraphrasic stomach.

Alright, so there is our fundus now free and loosened.

now look at that part of this that is where the the suture was on the other side my goodness yeah

what a disaster all right so i think we've done our fundus let's just have a look with our

nasogastic tube is in yeah that looks in position let's hold that over there like that just clean up

a bit perhaps we can say that they they performed not a yatter repair procedure but

at the Howard glass

repair studio.

It looks like there were sutures over here.

There is something.

Ja. Ok, now we're just

going to deflate the abdomen,

clean the camera, so we

can work again.

Right, stich.

Morsig, skoen lapjes.

Je steek mooi uitgesort.

Good.

Right, ok.

I'm going to put that there lightly like that.

Dankie.

Right, dit is vir jou helemaal weg.

Pressure is in the six.

Dat gaan aan.

Hoe kom pomp ons nie?

Er is lek iets.

We just trying to get pressure into the abdomen again.

Leiding pomp ons kruppeliks daar.

Waars ons verplees,

dus waars roef.

Kom, druk stop,

let ek net kan kyk,

wat is daar insufflation?

Druk stop.

Right,

druk die plissie daar onder die tien.

Huis op.

Ja,

sit om,

ja,

daar,

ja.

Oké,

en druk om nou.

Ja,

right,

start.

No wonder.

Kan jy dit check la die machine regers?

Dit is jou job Ruth, jy moet elke dag check

la die machine regers telles. Dit is

hoekom jy hier is. Right.

Sorry, our insufflator was just

dying, so we just restarted

that. Again,

pick up the cruise,

take a nice bite through the

fibrotic area at the bottom here.

Now one has to be careful not to put that stitch

through the vena cave, eh,

because it's encroached on the cruise.

That's a bit close. We'll just

Juste keer is dit wat ek nou vir Ruth sê, sê my machine is tel.

Ek check dat dit op ons naam is.

Want hy is so even een omfansie donkie.

Right, we pull the whole stomach and the esophagus over like that.

And now we're going to do the anterior closure.

Excuse.

Set that liver retract in a better position there.

Again, that same technique to get it closed up nice and snugly around there.

Once again, a great demonstration about the trick to push up both crura and then to go angulated and not transverse.

Not transverse, yeah, that doesn't work. That just doesn't work.

Oh, wait, this is not nice. The porter's got a cold.

Yes, of course, but you are too fast and you have to do it in slow motion.

we we don't have an instant to replay here okay we speed it up the video

let's see if we need to put another one posterior sir all right just bring our

livers vertrek die buik een beetje en so kyk hier nasogastic is nie in positie al right dit is een beetje

right uh maak in die nasogastic tube alstublieft

ja vaak met hierdie redos jy kan nie in die nasogastic maak nie, want dit is so gek

kinkt, push in, push in, all right, just hang on, stop a bit, okay, you can leave it in that position,

it's fine, scared him off, like, beg you up, now, now, it's still work, then if he keeps off,

I'll say donkey, right, that's our posterior window, there's the stomach, coming through,

there's the fat pad, gonna grab that over there, see if we can get, yeah, this esophagus is

Definitely a bit short, eh?

I know to do

that you're approaching the

fundoplication, and you said

there is an NG tube inside.

Will that be enough, or

you need a bougie to calibrate

better?

I don't use a bougie.

What I do is I

have a

18 French nasogastic

tube inside the esophagus,

and then once

as ek die esophagus gesluit het, moet dit, ek sê vir u aan die einde, 1 cm buiten die esophagus open.

En as jy die NG tube verloor, is dit normaal gesluit. Nou dit esophagus

sê vir ons dat dit een beetje kort sê. Ek sê, ons mobiliseer dit behoorlijk hoog, dit kan vir ons nie

hoog gaan. Dit is die antire vagus nerve, by die man, dit is die ene die daar inpull.

En dit is ons fundus, so ons het fresh fundus wat ons gaan doen met die nissen, en dan

to evaluate the patient post-operatively

to check that that

nissen is high up enough.

But I think that's all we can do at this stage.

She might need a second procedure

at the latest stage, one year down the line

if necessary

to put the nissen a bit higher

but not necessarily.

This stitch is true

the musculoskeletal is not

full thickness, of course

through this august.

I just put it, actually if you look

I put it behind the vagus.

I use the vagus as a pledget

I must say

I've never had post vagotomy syndrome

due to that

because if your posterior vagus

is intact, that's fine

and then

the stomach I don't care

whether it's full thickness

because it usually pulls in

and re-epithelizes

spanning out

you can see it's a nice bulky

nissen but that's also because of the edema

of the stomach, because if it's

inter-thoracic like that, because

of the negative pressure in the chest,

you get quite a bit of edema of that fundus.

As you can see, yeah.

Yeah, this is quite evident

about the edema.

So, of course,

I believe that in the post-op,

even the diet

will help.

Oh, yeah.

This is the

swelling.

Yeah, for sure.

Little trick that I do, yeah, is

I do my first knot

and I put it down

and then I make my loop and I keep that one there

otherwise it can sometimes just flop all over

the place

so I keep it there in position

and then I use that

so that

the knot does not come undone

and we tie them snugly but not too tight

Just because

again of the story of the edema

still in the post

op where

When will you remove the angiotube or will it stay for longer days?

No, the angiotube is taken out right now.

The patient goes back to the ward without the angiotube, this is fat.

And what I do is routinely on all my reviews,

I do a barium swallow the day after the surgery.

That's to make sure that the stomach is in the correct position below the diaphragm,

to make sure there is through flow of barium,

and also to check and make sure there is no leak.

Now you'll remember I said it's going to be right, see how tight it was, look there it's perfect, 5mm plus 5mm and the tube, right, there we are, that's done, and now we're just going to aspirate that local into the abdomen, ports out, there was a little bleed over there, nothing now, that's fine, no blood coming down there,

En terwyl die patiënt in die antiterre in Nellenburg is, gaan we die neemothorax asperate doen.

Sit op die buitenprenkie, die EKG-plak is op die verkeerde plek, hier so op voor op die borst.

Alle wetens waar dit moet wees.

So kom ons dit elke dag so doen, dat dit altyd die selfde is.

We gaan hier vir die tweede, derde intercostal ruimte.

En jy kan dit eigenlijk hoor.

En jy moet luister, wanneer die sukking stopt.

Dat dit stopt.

Right, and for safety, we'll just check the other side as well.

There's nothing that side.

Okay, that's it. Good.

So that takes care of this case, and now we've still got another case also,

something else here, that's also broken down.

So we'll see what is the mistake with that operation.

Thanks, and any congratulations again, once more.

It's been really brilliant.

So I'll see you, what, in half an hour time, or what?

Yeah, 20 minutes, how long did we take now?

Okay.

Yeah, 20-30 minutes, yeah, for sure.

Excellent, okay, have a good rest,

a good sip of beer, okay.

Great. Thank you very much,

my best compliments, thank you.

Thank you very much.