Heide Van Der Walt

Yes, good day.

Welcome back.

You're on the ball again.

Yeah, 15 minutes exactly.

Perfect.

We can make on to.

Stop.

Okay, again, quite an overweight patient.

But he's lost a bit of weight.

Also presented with classical achalasia.

We've tilted the patient

feet down, anti-trandelenburg.

About 10-15 degrees to the left side

And you can pick him up a little bit

Thank you

Right, he's got a much wider ribcage

First incision is over there again

Just in that little corner

Going in at Palmer's Point

With an optical troco without looking

There we are

Built by Fawzi Tafel, foot off

Flating the abdomen

Yes, good day

This patient, he's been walking for about 10 years

and for the last year, he's been sitting up sleeping

because of a regurgitation and aspiration at night.

But he's lost a bit of weight, so he's got a very long history.

Also presented with classical akalasia.

But he says it didn't trouble him.

We've tilted the patient.

I'm glad he couldn't swallow better because he's down and he's ill.

Maybe his wife is complaining.

And you can pick him up a little bit.

Thank you.

Right, it's got a much wider ribcage.

So our first incision is over there again.

Just in that little corner.

Piero, I sent you some documents.

I hope you enjoyed yesterday and today's documents.

Of course, by the way,

I already sent to you right now,

but you were always in theater.

So you can go up to date when you finish, when you're through.

Ok, fine.

Just want to go through there.

Just clean that again.

Now, I'll catch up on my...

How long is the symptomatology?

This patient, he's been walking for about 10 years.

Ok, so that's our 10 millimeter for the last year.

15 millimeters from sleeping.

Because of regurgitation and aspiration of night.

This is a very nice liver.

a very long eastern sea of fat but he sees it in troubling all right yes i'm glad he couldn't swallow

better because they need more bees next incisions let's maybe his wife is complaining yeah yeah

then five millimeter at the top here between the little corner of the ribs and the ziffy sternum

and that one in the mid auxiliary line halfway between these two incisions

Piero ek sien jy soe dokumente, ek hoop jy genoeg het gister in die dokumente van die dag.

Natuurlijk, by die manier, ek sien jy al, maar jy het al in die theater geweest,

so ek sien jy soe op-to-date, wanneer jy het gefinisieer, wanneer jy het gedroeg.

Ok, fijn, ek wil net doorgaan.

Ek sien dit nog een keer.

Nou, ek sal vir my verantwoordelikheid opstaan.

Daar is ek, vir my verantwoordelikheid.

sê dit patiënt het een

ok, so dit is ons 10 mm

troka, 15 mm

van die top van die artrie

ok, daar is ons, ok

dit is een heel mooie liwer

en een sea van vat

ok

hier is

gaan we die same approach

dat is die

5 mm hier, daar kan jy sê

daar is een kever, as jy kijk hier

dan, dat is die

en dit is die hepatik atri van die ribs

en die ziefesternum

en die in die middeleksilie line

halfwaar tussen die twee

we gaan die

we gaan die atri divide

swapping dit over

to a 8mm port

en dan 10mm

5mm

at the top

for the liver rod

nice fit

eddie matias

Yes, there we are, alright, see this patient has got a accessory lift artery, hepatic artery, there we are, good, alright,

alright, we need to go the same approach, opening up here, there you can see the vena cava,

if you look over here, that's the portal vein over there, and this is the hepatic artery over here,

That's the one we just divided.

We're going to divide the,

we routinely divide this artery.

That's fit, eh?

Edemartius.

What is this?

Pregnidie?

Arterie.

Oké, here we go.

Ah, that's a bleeder.

That's the one we just divided.

Again, this patient also has a

atis hernia, just like the previous one.

You see, that's the stomach.

But he's got a huge esophagus, a really huge.

Ein, during your preoperative work-up, during the gastroscopy, was the case to do, or if you have done a biopsy?

No, I don't do a biopsy.

Not on an esophagus, because if you do a biopsy, it's bound to get stuck, and you can get a perforation.

so, unless there is a tumor

or something like that, which will

of course preclude any surgery anyways

I don't routinely do a biopsy

in patients with achalasia

as a matter of fact, I avoid it

you'll see this patient has

a huge esophagus

this patient also has a

look at that

massive

you see that's the stomach

but he's got a huge

esophagus, really huge

vir Mark.

Clean die lens a bit.

Is the patient be kept

in a line

while during

Yes, this patient we admitted

five days ago

and fed him

Coca-Cola all the time

and he was on TPN. No, I don't do a biopsy

feeding.

Not to a softness because

if you do a biopsy

as I say, he hasn't got a softness

he's got a reservoir

and you can get a perforation.

So, unless there is a tumor or something like that, which will of course preclude any surgery anyway,

I don't routinely do a biopsy in patients with achylasia.

As a matter of fact, I avoid it.

You'll see this patient has a huge esophagus.

Really, it's like a big reservoir.

Look at that.

Massive.

Okay.

Alright, we'll loosen that there a bit.

Okay.

Supermark.

Clean the lens a bit.

Is the patient being kept in parenteral nutrition for a while?

Yes, this patient we admitted five days ago

and fed him Coca-Cola all the time

and he was on TPN for feeding

because we had to clean out that esophagus.

As I say, he hasn't got an esophagus, he's got a reservoir.

Let's just clean up there.

Spleen is behoorlijk in die positie, maar omdat dit mooi kyk.

Typiek van een man om soveel vat in te hou.

Ja, ja, ja, for sure.

Daar kan jy die aantere vagus nerve sê.

Daar is die posteriëre vagus nerve.

Right, so that's our

oesophagus over there.

Right, just clean the camera.

Oe, ja, lief.

Kan nie so ongekleer staan.

Ein, ein

in this particular case

with the mega oesophagus

pulling down

the oesophagus itself, is there

any risk to damage

the mediastinal pleura?

Uh,

it can, if they've got peri-oesophagitis

comes down quite nicely all right let's just clean this up in fact surprisingly surprisingly

looks better than the previous case yes it does right so that's how i'm going to there you can

see the vagus nerve i'm going on the left side of the nerve to make sure i clean the camera divide

the zing fibers we are leaf can this one clear sound really i'm in this particular case with

the mega esophagus

pulling down

the esophagus itself

is at any risk

to die gastonal pleura.

Right.

It can, if they've got

peri-esophagitis, that can happen.

But it's not something that

would worry me.

It's like redo surgery.

You nearly routinely open up

the pleura over there.

So, you know,

it can happen, but it's rather rare.

jy kan ook sê dat die esophagus best loos is

dit is volledig loos van die

van die omgevingstissie

dit is die longitudinele muskel

in feite, opvangend, opvangend, dit kyk beter

dan in die verlede geval

die ander probleem van die esophagus is dat hulle severe

stasis het, daar kan jy sê dat hulle dit bewaar

ek gaan op die linkere kant, jy moet opvangend sê

Soms kan die mykose vir die muskel verantwoord word oor die vorm van die esophageal mykose.

Ek moet dit makkelik neem.

Er is geen moeite om in ruie te wees.

Alweer hierdie kleine superficiële laai, dit is net om ...

En jy kan dit sê dat ...

Ja, jy kan dit sê dat ...

Goed, die esophagus is daar.

Ok, afwas.

Dankie.

Da, da, klima.

Right there, we've got our

landmark. We split the muscle there a bit.

Look how thick that muscle is.

And tough.

Now, the

longitudinal muscle is tough, but the

circular muscle is actually

very brittle. It breaks easily.

There's the circular muscle. This is the longitudinal

muscle. And I think this

guy is going to have a very thick...

You see now, the other problem

with these esophagus is they've got severe

stasis esophagitis.

So you have to be careful because sometimes that mucosa

can be quite adherent to the muscle

because of the information of the esophageal mucosa.

There is a little bit of blood.

Take it easy.

Once it starts bleeding, the uterine goes to the sphincter.

And you can see how avascular the esophagus actually is there.

That's going to start bleeding now.

Look how thick that muscle is.

And tough.

Now the longitudinal muscle is tough but the circular muscle is actually very brittle.

It breaks easily.

You know that?

And you can still see there's no bleeding.

It's dry.

There's a little bit of blood.

You can see now it starts bleeding.

Now you know you're out of the swing tail.

Once it starts bleeding then you know you're going out of the swing tail.

That's the oesophagus wall over there.

Ok, come down.

Right, now we're going to go down distally.

That's where I start bleeding now.

You know that?

way you should be there's our blood vessel can you see it there is a blood

vessel yes very well listen i know i'm just we were wondering

that the discussant professor russo which is next to me

bearing in mind that this landmark of the transverse

vessel is excellent is excellent

wat is jou gevoel om een extra identifikasie te doen,

om een endoskopie te doen,

een intraperitie-endoskopie,

om die lichaam te insuflateer,

om die muskels wat langer te gaan.

Ja, jy kan dit doen,

maar ek sê,

as jy doorgaan en jy op die muskels gaan,

dat, jy kan sê,

hy neerlie run vertikalie over hier.

Ons jy get to these vertikalie muscle

fibres, jy actueel vir jou swingtip.

En as jy kyk hier carefully,

jy'll sê, there's a little bulge hier,

a dent there,

there's obviously a bulge out there.

Now, I always say, this looks like a coke bottle.

There, and there.

You see, it makes that little bulge.

There's your blood vessel, can you see it?

That's your Z-line, and that's esophagus.

Very clearly.

That's another way of identifying and making sure.

Listen, I'm just

Just we were wondering

with the discussion

of a solution which is next to me

telling in mind

that this landmark

of transverse vessel

is excellent.

What is your feeling

about the

extra

identification

to do maybe

an endoscopy

vir die endoskopie

om die lichaam te insufleer

vir die lichaam

vir die brieke

muskies

ja, jy kan

jy kan dit doen, maar ek bedoel

as jy doorgaan en jy

op die muskies gaan, dat jy kan sê

hulle bijna vertikale

over hier, as jy

vir die vertikale muskies

vir jou swingte, en as jy

sê, jy sê, dit is

een litte bulge, een dente

there, and then a bulge out there.

Right. Now, I always said this

looks like a coke bottle, there,

and there. You see,

it makes that little bulge. This is stomach,

that's your Z-line, and that's esophagus.

That's another way of

identifying, making sure,

you go distally. Right.

But I mean, you can use an endoscope.

I've heard people using manometry

intraoperatively to

determine that.

I don't really think that's

necessary. Nice big bite of that.

But you can do it.

Keep it over there.

Yeah, if you look at this esophagus,

you can see, this is

easy 50-50,

so we're not going to put in sutures over here.

There's our stomach.

Okay.

Keep it there.

Now we're going to do our toupee.

Okay.

thing.

Keep it over there.

Stop.

Ek moet uit daarom ek het om nog vast te afzoek.

Good.

There we are.

Met achteen kanale op die, ja, maand.

Ek het sien een grill.

Ek moet so'n piekie ontspun en s'weer naas, he.

Good.

There we are.

Ek het sien een grill.

Ver en diep oor.

It's a big guy.

Keep it like that first.

Ek maak hierdie posterie stik daar.

Ja, jy weet, Piero, die ander ding is, jy weet, jy klos nie die hiatus in hierdie geval

soos jy met een normaal hiatus hernieuwe reparatie doen.

So, die kans van hierdie hernieuwe en ontwikkelde hernieuwe is hoger.

Dit is een groot dier.

En dit is waarom ons hierdie aardappels soos dit doen en soos ons dit stik.

Ek het ongeveer, ek dink in die laatste kaunt, ongeveer 400 LMI aardappels gedoen.

So, geskipteerde aardappels geef jy iets.

En dan gaan we die andere kant draai.

Hou dit soos dit eerst.

En maak hierdie posterior aardappel daar.

Ja, jy weet, Piero, die ander ding is, jy weet, jy draai nie die aardappels soos dit,

In these cases, as you do with a normal hiatus, hernia repair, so their chance of actually herniating and reverting, herniation is higher.

Genia, you can see very nicely there, that's why we close up these, these, where they join.

Hiatus is like, and stitch it like we do.

I've probably done about

I think in the last count about

400 LMI-automies

so

experience teaches you something

must be careful

that you don't stick it through the esophagus there

and damage the mucosa

and

the toupee that I do

normally if you do anti-reflux toupee

it's usually between

240 and 270 degrees

for the achalasia

as so the previous case 80 degrees okay just keep that straight like that a little bit tension

again yeah you can see very nicely that stomach in fact as you said initially there was a 50 50. so

of course the the antiflux is smaller shorter yeah yeah for sure

must be careful that you don't stick it through the esophagus there and damage the mucosa

and the to pay that i do you've normally for you anti-reflux to pay it's usually between 240 and

270 degrees now the circular base we only make it 180 degrees muscle fibers

In fact, as you said initially, there was a 50-50, so of course, the anti-flux is smaller, shorter.

Ja, for sure.

Let's also make it not too tight, otherwise you cut through the muscle.

Ops, so there is, eh.

Maak jy terug, oké.

Let's pick up a little bit like that, there we are.

Now, the circular muscle doesn't really have any stent in this suture.

It's all about the longitudinal muscle fibers.

Also make it not too tight, otherwise you cut through the muscle.

I'm concerning the fat pad that is just in front of you.

Yes.

It's going to be positioned onto the esophagus or just as it is?

Just leave it as it is.

Yeah.

Also in this particular case for the post-op,

Hemingad, Hemegasovagus, die N-tube is gaan verblijf en die TPN is gaan verblijf vir langer of nie?

We take out die nasogastie tube, he'll go on with the TPN, we'll do the Berm swallow tomorrow

and if you've got good through flow, which I'm sure he's going to have,

we'll just continue the TPN for another day or two and he'll progress with his diet.

Daar is ons, daar het ons ons myotomie.

Daar is die toupee, op beide sida, 180 gradies.

En die mykoos is mooi en open,

langs die onderkant.

Goed. Daar is ons, dit is dit.

in a very dangerous

manoeuvre

as it was

cutting the muscular fiber

just stretching them

in a real so fantastic

this particular case

you don't need to use

I mean you saw this case

it's bone dry

you really don't need to use

no water in

we

we take out the nose gas

you'll go on with the TPN

we'll do the bear and swallow tomorrow

tomorrow, and if you've got good

flow, which I'm sure he's

going to have, we'll just

continue to keep in for another day

or two.