Prof. Heine van der Walt Sud Africa

Our case is a male patient that presented with quite a long-standing history of achalasia.

He was evaluated with manometry.

I think he came with a barium swallow as well.

And on the endoscopy, he had the typical findings of achalasia and also on manometry, classical achalasia.

So we've got our patient here.

We're now going to tilt our table, feet down.

Stop.

Yeah, that's fine.

Yeah.

Good.

Now come a little closer.

Focus on your bike.

Stand on it.

Come on.

You have to stand there.

Focus on your bike.

Zoom in.

right now the placement of our ports we're going to use a five port technique that's the

ziffy sternum over there that's the rib edge over there the rib edge over there the umbilicus down

here as you can see so our first port is going to be on the rib edge at least about 12 to 14

centimeters from the confluence of the ribs not the bottom of the xiphi sternum

but the top of the xiphi sternum so we're going to make a little incision

there and that's going to be incision just for a 8 millimeter port but we're

going to insufflate with a 5 millimeter

right we're insufflating the abdomen to a pressure of 15 millimeters mercury

that's got quite a big belly this guy oh yeah maybe you should

Time me up.

Good.

All right, now our next port is going to be for the camera, and that's about 15 centimeters

from the top of the Ziffy, and that's going to be a 10 millimeter port.

I'll set it like to begin.

Mark square.

Okay.

We'll let my hand knock off here.

There's our camera going to go in now.

Now, our next port is going to be between the camera port and the insufflation port.

That will be halfway in sort of a semi-lunar half-circle, and that's going to be a 5mm port again.

Then we're going to put in a port, and I just want to see how big is his liver.

Oh, it's nice and big.

We're going to put in a port at the top here.

that's between the rib and the ziffy sternum and then halfway between those two slightly more

lateral in the mid-axillary line would be another five millimeter port then we're going to swap the

five millimeter port here for an eight millimeter port and the reason why i use an eight millimeter

port is that a 20 millimeter or 26 millimeter needle can easily go through that you don't need

bigger right so this is our configuration eight millimeter port in the left hypochondrium

10 millimeter camera port in the midline 15 centimeters down a five millimeter port between

these two ports between the ziffy and the rib cage over there we've got a five millimeter port and a

five millimeter port in that area on the lateral side right now we're going to put in our instruments

and elevate the liver.

Yeah, can I work on that?

There we are.

Right, we're using an Olympus 3D system,

as you might have gathered from our spectacles that we have.

Ah, he's got a nice big floppy liver.

We actually got him to lose a bit of weight before the surgery

because he was quite, despite his dysphagia,

he was quite overweight and he's not very tall

and he weighed 115 kilos.

And I'm going to use the Olympus Thunderbeat and my instruments are the Storz ClickFix.

Now we're going to open up the Pars Flacida or the Lesser Aventum.

There's a little artery over there, we're just going to cauterize that.

Alright, there we are. Good.

Right, now there's the caudate of the liver that's overlying our landmarks over there.

it's almost a big swap yeah i'll say there we are good now we're going to open the itis this one

grab this a little bit fat this is getting into the right plane over there there you can see the

posterior vagus coming through once we get in under that little layer there that's our layer

that we that's where we have to go right just going to just open up there there you can see

the cruise on the left side we're going to pick up the esophagus a bit there divide the tissue

over here and loosen up the esophagus we'll do that a bit better it's got quite a lot of fat

the nerve, alright, good, I'm going to take the short gas, if you do, if I do a hair

myotomy I usually do it to pay if you do a door you probably don't need to take a

short gaseous but I found that if you don't take them the the door actually

gives you quite a bit of tension on the itis area and it's sort of like

misformed it's I never get a good position if I don't take down the short

So we would routinely take a short gas six.

That's fine.

Here we go.

What do you think Adel?

This one?

Yes, you have a little bit of pressure.

Try to get up.

That's still a bit of pressure.

Right.

All right.

Piero, we have difficulty hearing your voice.

I'm sorry.

Can you hear me?

The length of the maotimi.

I usually do at least five millimeters proximal, usually much more, and two distally.

So I abolish the lower esophageal sphincter completely because I'm going to do anti-reflux procedure.

The old story of doing just one centimeter distally on the stomach, you usually end up with an incomplete myotomy.

So I always do a proper myotomy high up enough.

And, of course, if it's a type 2, type 3, especially type 3 dysplasia, then I go up quite a bit higher on the esophagus, up to 10 centimeters sometimes, depending on what we see on the X-rays.

So there's our stomach, fundus, loosened.

There we are.

But first, why does the esophagus isolate when you have to do just the myotomy in front?

Even now, why?

I'm gonna do it to pay. That's correct.

All right, so there we've got our esophagus.

here is the fatty pad the fundus of the stomach now the first step that we're

going to do is to do the myotomy you can see the patient also has a rather large

hiatus so despite the fact that he has achalasia we are going to close up his

hiatus and what I normally do is I close up the hiatus with a toupee so

So that 50% of the space is occupied by the esophagus and 50% space.

And if you do it bigger than that or you leave it like that, they herniate and they get parasophageal hernias.

Right, so now we're going to start off by taking the fatty pad over there and over there.

Now again, the position of the myotomy.

Traditionally, the original helomyotomy was transthoracic and the helomyotomy was on the

left side to divide the sling fibers.

Laparoscopically, most surgeons actually work on the right side of the esophagus and they

divide what we call the clasp fibers.

I do it on the left hand side I like dividing these fibers over here and I go

to the left side this is our vagus nerve actually lying over there encroaching

the fat so I go lateral to the vagus nerve I actually use it with for

traction as well so what we're going to do is to start off by dividing the fatty

pad to go right down to the stomach you can see there's a little layer of fat

over here i'm just going to divide the superficial layer with energy and that's the only energy i'm

going to use on the esophagus just to clean up the muscle so that we can work and see properly what

we're doing right you can see the liver of the patient's a bit bigger it's going to maybe shift

that liver retractor into a better position over there right so we've got that over there now i'm

going to grab that one over there i actually grab the vagus as you can see i use that for traction

right so it's just the fat again dividing the fat a little bit of prank is better awesome

right we're just going to clean the lens at this stage just going to loosen that as well

okay clean the lens just deflate the abdomen now the rest of the myotomy i actually do with blunt

dissection i don't use any energy on the esophagus at all um you can just touch the mucosa of the

stomach oh that's falling down let's just pick this up again all right excuse me i'm here

commenting with a big surgeon from milan dr roberto russo which was wondering why are you

doing it to pay rather than a door with this light situation there are two yeah

I I just prefer the to pay I as I said I don't like the door I've actually I used

to do the door but they have quite high incidence of reflux afterwards and what

else happens if you do the door it hangs on the esophagus and it actually

It actually angulates the esophagus there, and I know I've got no randomized double blind study to prove it, but my initial thoughts were that these patients actually have a little bit more dysphagia, and that's why I actually switched to the toupee.

Okay.

There's nothing wrong with the door.

I just prefer the toupee.

Okay.

So, is that a personal choice?

it's a personal choice but I mean there are many surgeons that actually rather

do it to pay than a door if it comes to the achilles here right there we are

good now we're going to start off with our myotomy