DE MANZINI ERNIA

Very well. Now we are starting. Welcome back to Trieste.

We are starting with the second operation. The clinical case will be presented by Dr. Trojan. Please.

Her past medical history is with abdominal surgeries that are appendectomy.

She came to our attention for syndromes related to gastroesophageal reflux disease.

disease, she especially had during the last period an increased sense of heartburn, difficult

swallowing and therefore she performed a duodenoscopy that showed the possible existence of a parisophageal

hernia. For this reason, she performed also a CT scan that showed the presence of the

the hernia. Diaphragm is of three centimeters. The stomach is herniated through this defect

in the thorax and also the gastroesophageal junction is dislocated within this hernia.

Okay, now the trocar position is quite very regular.

The scope is positioned at exactly 10 centimeters below the end of the sternum.

And then we have an epigastric trochanter for an S-shaped retractor and three other instruments for my right hand, my left hand, and a fourth one for achieving a stable retraction of the stomach.

Now you see we have retracted the left liver.

Previously we have removed an occasional third segment angioma.

waiting for the connection now the left lobe the caudate lobe and we start with the reduction of

the gastric hernia okay the spleen is not was not inside so now we have a quite clear exposure

of the left pillar, of the right pillar here, and of the complete part of the phascial part,

the aponeurotic part of the diaphragm.

Now, first approach, normally in a reflux disease, we start with this retroesophageal passage,

passage, opening the pars condensum of the little epiplon. I am not sure that I will

be able to do it now for this case, and it is not mandatory to do it immediately as a

first step. The first step will be the reduction of the stomach and of the sac of the hernia

into the abdomen so let's go to do it we start with the okay I reopen well the past condense

of the little epiplen and try to dissect the to dissect the left the right pillar that way

And I will try to avoid cutting here, but I try to cut here.

Why? Because I try to maintain a little part of peritoneum, of perimysium, around the right pillar you see here.

So I try to avoid removing the very thin fascia that surrounds the muscle in order to try to ensure a better resistance of tissues when we will perform the iatoplastic.

Here I have just to remove some adhesions of the small epiplon, trying to avoid the

opening of the right pleura you see here.

It is not a very big accident to open the pleura, but you can suture it.

You can even leave a small hole open because there is not a pneumothorax,

but just an intraoperative capnothorax.

So now you see what I want to do.

Avoid cutting here.

Prefer cutting here.

so that the muscular layer of the right pillar remains covered by a peritoneal surface.

Normally, when we operate a reflex esophagitis, we start with the dissection of the pillars,

and just by final exclusion, we go finding the esophagus.

Now, we have mostly, of course, to prepare the pillars, but also to remove the sack of the hernia.

And the maneuver of surrounding the esophagus is not necessarily here the first one to be done.

done. Nevertheless, you see that it is quite possible to do it, but really I will wait

for and I will reserve this step of the operation in a second moment.

Now the important thing in my mind is to continue to resect the neck of the sac avoiding to

to make the vagal nerve, avoiding to make the pillar completely naked by its peritoneal surface.

In effect, we have to restore an anatomy, and restoring the anatomy,

You see how the pleura, the right pleura, is like fascia transversalis in a direct inguinal hernia.

But you can just push it.

What I wanted to say is that we have to restore anatomy without damaging physiology.

physiology, so that we have to restore the anatomy of the yatal region and to avoid a

post-operative reflux.

Okay, this side and this superior side is quite completed, and you see that that way

I should be able to divide the neck of the sac from the esophagus and to push as far

as possible the right and the left pleura thereafter probably I am pushing

too far so now I will use a smooth and gentle

grasper to maintain for the moment the gastric fundus inside the abdomen

Okay, now I have to continue for that way here.

And you see the attention that I try to have to .

You see that I try really to avoid to put the peritoneum out of the layers of the pillars.

No one has a scientific demonstration that leaving the perimecium around the pillar is better.

It is just an expert opinion, so the degree of evidence is completely subjective.

But anyway, I think that nobody could imagine to prepare a randomized trial about that.

And you see that in a good plan, you should be able to retract the sac of the hernia

in order all these parts should be removed.

What is proven is that leaving the sac inside the mediastinum

could result in a, not necessarily in a relapse of the hernia,

but in something completely unusual.

Now you see very well the left pleura,

and we are going to try to retract completely the hernia sac.

Of course, the hernia has dissected the mediastinum by itself,

I have just to retract the, and just to understand where I should exactly cut here, probably here.

This is not an esophagus, right?

No, no.

Esophagus posterior.

Esophagus is far posterior, so I have to cut this adhesion made between the Leimer-Bertelli membrane,

the phrenosophagial membrane, and the sac of the hernia.

Now probably the sac is here, and we should be able to find finally the naked esophagus, vagus nerve, and the right pleura.

Once we have freed the pleura, it retracts.

You have seen that once the pleura, both the left and the right, were attached to the hernia sac,

we were able to attract them into the abdomen.

And now that we have solved this kind of smooth adhesions, you do not see anymore the pleura.

Okay, the posterior vagal nerve is quite easy to see.

Now I try in this region to find out the left pillar, here it is, and I should try to join it from passing below the esophagus, perhaps that way.

way. This direction I enter the pleura. This is not good. You know very well that no matter

the position you put the vagal nerve, the vagus could be left near to the esophagus

or far from the esophagus. You can put it inside the fundoplicature or outside. There

There are just very old papers talking

about the role of the vagal nerve

in the stability of the Nissen procedure.

Now we know very well that the main problem is another.

It's not, of course, not the mechanical role

of the vagal nerve.

Let's go over here.

Try to turn the sofa over.

I do a first attempt to see if, yes, if I succeed in passing through the rear, below the esophagus, behind the esophagus.

Not at all, not complete.

Puttalo verso la mezza di nuovo.

Okay, so the dissection of the esophagus and its reduction into the abdomen is not completely achieved for the moment.

Perhaps I have to cut something here.

And I'm looking for the inferior part of the left pillar that could be the path to follow the good way

way in order to pass behind the esophagus without entering in the left pleura.

So I follow the right pillar and normally I should achieve the left one, not so evident

perhaps here because mainly the main reason is that the due to the illness the tiller are very

inconsistent perhaps here and they don't want to cut any other structure okay perhaps it could be

the good way but there is some some more remnant additions for the from the sack I think

And I prefer to cut them out.

Okay, piano.

Centrami un po' di più d'immagine, perché quando poi...

Okay, let's go and see if the passage is the good one.

Okay, dalla fettuccia.

Puoi tirare via questa.

Okay, the retroesophageal passage is done.

Bisogna inserirla da qua.

Il manderino del trocker, per cortesia.

Qual è?

Grosso.

not otherwise with clips or other thing it never remains solid sorry okay

okay okay now we should have with this with this not a possibility to move the esophagus to put

it under traction to to move it towards the spleen towards the esophagus towards the feet

and to make our dissection perfect with all the details and moreover we should

have an easier space to suture to prepare the

Anesthesiologists will have to put a big tube, right?

Yes.

We will ask...

It will take a while.

It will take a while.

But you can already aim it in the mouth and let it go down in the esophagus a little bit,

so it will be ready at the right time.

I asked the anesthesiologist to insert a 45 French tube into the proximal part of the

the esophagus in order to be ready at the moment in which we need a calibration of the

iatoplasty. You are seeing quite well the posterior vagal nerve. I push just a smooth

dissection into the posterior mediastinum, the right pleura, pericardium here, just to

to have an easy lowering of the esophagus at the moment of fundoplication.

You see also the left pleura here and the first part of the left pillar here.

Unfortunately this first part I didn't succeed to maintain the peritoneum over it, but probably

Probably if I succeed in passing my first stitch here, it could be well.

Mi darà aspirazione, suction, just to clean out.

Si fa irritare.

Prego.

No, no, va bene.

Si va.

Ok, perfetto.

Ok.

He has a cow that's low, very hypertrophic, but don't worry, I do not resect it.

Ok.

Okay, first consideration, pillars are not so fibrotic, so we can start the iatoplasty.

Prepariamo i punti, cara.

Just before starting the iatoplasty, I want to see one more thing, where to put this stitch.

Here, fine.

And now, vieni dietro con l'ottica, guardiamo le soffole dall'altra parte.

and now I just want to check if the dissection of the left pillar is near

complete yeah you see the dissection of the esophagus from the left pillar is

really complete here you see the aorta this where is the spleen somewhere here

here, but don't worry, if I don't, I'm not, I'm not very unhappy if I do not see the spleen.

Okay, now we are quite ready, so my proposal is to put the first stitch, or the first of

the second and in order to have a very wide space to work it's just after i will ask the anesthesiologist

to to push the the calibrating tube non-absorbable plurifilament two zero or zero

I start very low, I avoid to pick into the caval vein.

This patient has an anatomic particular that the caval vein in the lower abdomen crosses

the aorta and becomes left-sided, but for us it's not important today.

wrong okay should avoid to provoke some mistakes with the needle stitch should not be too tight

and the first node must be inverted immediately so that you can make it flow.

See?

Yes.

If instead you make two contemporary nodal planes, it will block.

I stole it with my pink eyes.

Okay, the first one is done.

Of course, we consider then a reinforcement with the mesh.

For many years, we have used non-absorbable Gore-Tex meshes,

especially designed for

hiatal hernia repair and honestly

over not more than 10 cases

for the moment

we haven't seen

any relapse or any specific complication

like migration into

into the stomach.

Anyway, in literature, it seems to be dangerous.

And so that now we will pass to semi-absorb to meshes with a

.

Now we will see in a few minutes the esophageal tube going down.

Okay, we see you, molle un po', Biagio, scendi ancora.

Okay, stop così, Biagio tira di nuovo.

Okay, stop, and you see now that my stitches

are passing through the muscle,

but also through the peritoneum.

I try to avoid picking the vagal nerve.

Should be a good thing if I succeed in doing that, yeah.

Yeah, okay.

Some people prefer to use monofilament proline

in order to have a better gliding suture,

but sincerely we are used with this kind of suture

for hiatal hernia repair,

and so it's just a personal opinion

of what could be the best way of suturing.

up now with this kind of nothing I should be able to let the thread be reinforced now with try to

see if it is real broken and now almost blocked sorry no no quite good of course the the goal

The goal is not to strangulate the thread, the muscle.

OK.

Sorry, I will just put a because my knot

is not so good.

Normally, with just one inverse knot,

you can make the knot gliding, but it was not the case today.

of course due to demonstration operation okay no I remove I remove I redo the not not so good

should remain all over the life of the patient unfortunately i have to redo but at least

solution could be the to use a third grasper to maintain the first knot stretched tight

Okay, that's good, but it was only the first one.

Okay, preparo un altro, ovviamente, foro sul fegato.

Okay, ultra.

Okay, now I have to redo the second stitch.

Now it is not so tight, but it is what I want it to do.

Okay, the second one.

Perhaps rarely at the end of the procedure

procedure, you have also to put an anterior stitch of fundoplication that is not so common.

Now we will see. You see that the left pillar, the left pillar is much tougher, much fat,

perform a better knot than before I say I try to do a better knot not the worst one okay now second

Second technique, double knot first and moderate traction to maintain it closed.

Okay.

Better than before.

Probably .

You see how the left pillar is fragile.

That's the reason why we will put this prosthesis.

to, aspiratore prima. We can try to pass the last one. Ultracisium, un attimo. I just want

want to remove this thin membrane.

Otherwise, you should try to see if, yes, it could be useful.

Now, we have to put the prosthesis

and to perform the anti-reflex system.

But just before, we don't have to forget

get to remove the hernia sac that

could represent a dangerous and unuseful volume

inside the fundoplication.

OK, for ultra.

OK, I'll go for it.

Aspiration.

OK, you see that the passage is narrow, but not too much.

And ultracision.

Now I just want to remove all the tissues of the hernia sac, at least the biggest part,

in order to have a clean fundoplication and not something with this unusual tissue inside.

side. Why I remove it just now? Because sometimes it could be useful to maintain it until this

phase in order to have a good traction if necessary on the esophagus without doing any

We are ready for the prosthesis.

We pass the knot over the stomach in order to have a clear,

almost clearer vision of the descended esophagus.

perhaps the knot is too tight. We will check it now. Fine. Fine. Fine. Okay. Now we have a clearer

esophagus in which we can thereafter prepare the fundoplication. Fine. Aspiration.

OK, the field is clean to put inside the prosthesis.

OK, let's go.

What type of mesh do you use and why?

Thinks like this.

Yeah, just a moment.

you have seen that during the suture the clear impression was that the the right

pillar was a particularly thin non-fibrotic smooth and the clear vision is that the clear

clear impression, not more than impression, is that it cannot be able to maintain the

strengthness of the stitch all over the life of the patient.

So, now we try to put this prosthesis that is a long-term resorbable one,

allowing that the scarring could be protected for six to eight months

until the stabilization of the crura.

You know why the non-restorbable meshes have been described as dangerous for the risk of late penetration inside the esophagus.

as even if our small experience of 10 cases of a PTFE prosthesis

never led to such a dramatic result.

Nevertheless, you know that the complications of the old

the old angle cheek prosthesis of more recently of some gastric bending for obesity and so in

literature now there is a soft coming back to resorbable prosthesis and nowadays the industry

gives us some prosthesis with

a long resorbable time. That means

that the risk, that

the idea is to have a good compromise

between the strength, the immediate strengthness

and the late risk of migration.

So the strengthness is ensured for some

more and the risk of the late migration is avoided by the long-term disruption of the prosthesis

prosthesis that i try to put in the good position for the moment i don't succeed

Let's go to the other side.

Not enough.

Okay, position is good.

Now we have to fix it.

Okay, positioning is good.

Now we have to fix it.

You see that prosthesis doesn't go all around the esophagus,

but just protects the main stitches of the atoplasty.

is once you have correctly positioned it in the right position, it is sufficient to fix

it with a limited number of stitches as the movements, the displacements are very, very

improbable. So probably we will do better, but probably with just this stitch and the

control lateral one you should be sure about the maintaining of the good position okay ultra

The trick is to go more than 180 degrees but to perform a quasi-complete circular suture.

You see? So you leave the place.

The prosthesis is not a circumferential one but almost circular.

the positioning of the mesh, and now the fixation takes time and it is not more than technical.

see if we have to put a stitch. Inferior is completely unuseful. Perhaps here a stitch

could be dangerous because... Mi dà un ago comunque. Mi dà prima una Joanna. Now the

So the problem is to understand how to complete the fixation, because here it will be anyway

when I perform the nissen, it will be self-staying, but perhaps the stitch here could be useful.

The problem is not to create a pneumothorax, a cardiac tamponade,

and such a bad thing you can find on the other side of the diaphragm.

So very smoothly here.

Yes, you can use glue, it's better.

For the moment, we prefer the fundoplication.

Okay, now we prepare the fundoplication, and just in between, we put the fibrin glue in

the rear part of the mesh.

Okay, you see the fundus gastric.

Perfect.

We are preparing for the fundoplication.

I try to do it more looser, this could be a good way, this classical test, stitch, punto.

We are approaching the end of the operation finally, the half valve posterior valve stays

stays in place here, you see, it doesn't move so that it means that it is roughly very loose.

This first stitch is always a test because you could be pushed to remove it after the

positioning of all the stitches but anyway you have to try we have to try to do a good knot

for this phase of the operation nothing is considered to be helped by the 3d camera

we do not have it for the moment but okay very well so is a short

Okay, clip, why do I, I am going to put a metallic clip here, because I wish to have

an easy radiological landmark of the position of the fundoplication.

is absolutely not for ensuring the knot, but only for being able to see very clearly where the fundoplication is.

Another point that could be the last.

Am I out?

Yes.

Another point that could be the last.

The last one, the glue, what point are we at?

Yes, yes, I went to order it.

We could also put some glubran points if we want.

We are going to remove the big gastric tube, the calibrating tube, completely.

And we administered a strong anti-emetic in order to allow the patient to have a liquid diet tomorrow

and if possible to leave the hospital the day after tomorrow.

How does it remain?

the glue for fixing the for fixing the measure and the last gastro gastric point the so-called

this is the clip where is it? yes, let me see it, ok, give me a clip first then we clean the

camera we are going to the last detail i want to remove the wrong clip i have put before for it

cleaning the optical and just putting the last gastrogastric stitch the as i thought as i

I said the so-called Rossetti stitch to avoid upper migration of the fundoplication.

Of course, in this particular case, it seems to be more theoretical than others because

we have a process, a mesh.

But nevertheless, we try to perform every time the same operation in order to at least

to be able to compare our own results without any otherwise if even in the same team we

have differences it could be very difficult to understand mostly the bad results even if in

literature now it is more than clear that nissen from the application not should must be short

short and soft and and floppy okay this is the last okay the ultra and now the glue the glue

excuse me let's keep the bow until the end I go out ok in the end for pleasure we will turn on the lights

Can you give me a panoramic view with that camera over there that we're saying goodbye to?

Is the glue black?

I need a long tube, though.

And with that needle?

Sure, sure.

In the hernias we do it like this.

Yes, ok.

We are just a few seconds, we are waiting for the glue.

We just need to put a syringe of some kind.

A syringe of insulin.

Give me the mandarin.

Give me the mandarin.

And then I'll put it away when we're there.

Ok, go.

Let me see where it is, so I don't pierce my liver.

Exactly.

Let me look for it.

Let's do something else.

Here.

Ok.

Let's go clean the optics.

Yes.

Ok, just a moment to clean the optics.

Ok.

Ok, now remove the mandrel, the syringe to travel, the syringe here you have to go very slowly.

Where is the mandrel? Ok, hold the syringe to travel.

Another grasper for me and we are ready to...

No, we have to clean the optics, just to finish the operation, sorry.

5 minutes and we have finished ok ok ok ok ok very well

just to to get a good exposure because he then now ok

Ok, push, push, push, push inside, push, go, yes, stop, back with the needle, ok, come back, I've already found the needle.

No, now, go, go, go, go, go, wait, I pull a little less, ok, it's going, ok, stop, go needle, go needle, pull it back, come back with the optics.

Can you hear me, Trieste?

Yes.

Okay.

Yes?

I wanted to tell you that the professor is removing you from the screen for a moment because we need you anyway.

Yes, but we're done.

We're done.

Ah, perfect, perfect. We just wanted to warn you.

Okay, we'll see you...

Wait, we'll see you in how much time for the next intervention?

Look, at this moment I have a ladder in front of me.

I'll ask and I'll let you know.

thank you yes go away ok we are done ok we have no gauze we have no

other final little vision perfect good go to the snake and lights