Heine van der Walt Laparoscopic re-do repair of recurrence hiatus hernia

as i tilt the foot off okay and come to stop pick you up there we are thank you right so we use

the normal port placements that we use for the hiatus hernia yeah the problem with uh

the redos from some elsewhere of course is that you never know what you're going to find

and sometimes a bit of a

surprise, often.

We need to pick it up.

How long, sorry

Hein, how long after the

first operation was there a relapse?

Very,

the first operation never worked.

So she had her operation and we're going

to now see what the mistake

is and what was done here.

So she

actually just had to continue

on her PPIs after the surgery.

as jy op die binne breng jy of beter

ek klink soos my kunnes

ja

oh, it doesn't look too bad so far

oh, that does

you can see this patient was operated

with a endostitch

those are endostitch sutures sitting there

it's a horrible instrument

we're just gonna clean the lens

right, let's just loosen

the caudate lobe of the liver

don't know it's always the best thing to tie and get your first planes posteriorly it's much

easier than trying to get in anteriorly because often the you can't distinguish the esophagus

and the cruci in the normal tissue

because it's all muscle.

Ek het baie steken en gesit.

Goed vast werk.

Apart from the symptoms that she

definitely had, but how

did you work her up

preoperatively?

She had endoscopy,

biopsies,

24 hour

pH study,

and manometry.

I didn't do any radiology.

It wasn't necessary.

And with the endoscopy you could already assess that the stomach was in the chest?

Oh yes, yes, yes.

We'll see when we get it out, there's a big piece of the stomach in the chest.

What the hell is this?

It's the problem that, or the mistake that was made with this patient's operation,

because it's a surgical failure, it's not a patient failure,

is that the stomach was put around the stomach to start off with.

So you've got the stomach, then you've got this nissen that was done,

but above the nissen

there is still a big piece of stomach

you can see, this is all coming

out of the chest

so you mean that the crura

were not addressed at all

no, the crura were addressed

but the nissen was done over here

but there is the stomach

over there, you see now

so the stomach was put around the stomach

that was the, you see there is the

fatty pad now, see where is

the stomach, there is the

Now it's put around the stomach.

It should be around the

esophagus up there.

So the surgery was done incorrectly.

It's not a slip, Nissen.

It's sutured there.

It was a low, Nissen.

Ja, the operation was just done incorrectly.

Refinise the carousel pipe.

So let's loosen this

short gaster here.

Jy, wat is gaan hier?

Ok, let ons

gaan luister dit. Ek wil dit

uit. Dit is een mes.

Nasus, Mox 20 lens.

We are just going to clean the lens

again. Right, there we are.

Kom, Radar.

I think it is difficult to recognize

the Vagai in this situation.

Yeah, it can be very difficult.

Very difficult.

You don't know what is here.

Here is the nasogastic tube, we'll put it through now.

Let's just loosen this off, this crucian as well.

It's fused.

Ah, there we've got a pneumothorax, can you see?

Yes, absolutely.

Yeah.

See the lung.

Yeah.

I'm just checking the anesthetic of course, you know.

It's the only reason I do that.

But in these cases it's inevitable, I mean the pleura is stuck and everything is fused, yeah.

Will it be sufficient to suck the air, or will she need a drain?

No, I never put a drain for these.

Look, it's not a lung leak.

It's air that we put in there.

Now you can see, this is all still stomach.

There is the esophagus.

So now what we're going to do is we're going to dismantle this nissenia,

or whatever this was.

Kijk wat gedeelte van die lichaam is aangetrokken.

Daar ben jy, dit is die korpus.

Kijk, kijk dit.

Ja, dit kan jy heel goed sê.

Die korpus is daar, dit is nie die fundus.

Ja, dit is verloor.

Totale verkeerde

techniek,

die jy eerder gebruik.

Ja, die konfiguratie is onverstaanbaar.

Nou, nou gaan we die lichaam wegdoen.

Breng dit terug daarnaar.

Daar, daar is nog karret.

Achttien.

A, en goedemiddag.

How are you?

Anuncio?

Yes.

Hi, Tricarico, how are you?

It's wonderful to hear your voice again.

Yes, yes.

Just to say

good morning because

I have to

back to Naples.

But I have seen

your operation

really

like always

performed

very, very, very well.

Oh, thank you. I'll keep you well.

You are fine, yes?

All fine?

That's lovely.

Just push the noise against the cube in for me.

Ah, that's wonderful

hearing your voice, Anuncio.

I'd love to speak to you. I'm coming to...

For me to see you.

I'm coming to Italy again

in June next year.

I'm coming to visit.

Okay.

It will be wonderful to see you

Have a nice day

Thank you very much

Bye bye

Thank you, bye bye

Bye

Right, okay

Let's see what we can fix here

My goodness, okay

Hello

I'm Marko Svieski

I got a question

in your opinion

the main mistake

in the previous

procedure was not to

isolate

the esophagus

into the chest

yeah, for sure

the mobilization

was not done correctly

and the esophagus was not

exposed properly

so what happened is that

the wrap

was put around with

as you can see, the fundus

that's the corpus of the stomach over there

that was put around like this

instead of the fundus

put around the esophagus over there

and this is all stomach, if you scope the patient

you can see there's a piece of stomach

then there was the fundoplication

stomach around stomach, and then

the distal stomach, so the problem

was that the, you can see

this esophagus is virgin, I mean there's

there's no work done here

yeah yeah yeah right well let's fix also that the the gastric vessels are uh in the place in

their place there's no no uh dissection on the founders that's right yeah you see i had to

loosen these short gas sticks over here it looks like they might yeah i don't think they have

actually even took any of the short

gas sticks. Again,

you know, that was that old story,

always, you know, it's not

necessary to take the short gas

sticks, you know, the Rosetti operation is okay,

but it's not okay.

They slip, and they get dysphagia,

and they can't belch,

and they can't burp, and they get gas bloat,

and they're just not satisfied.

They exchange

one symptom of

heartburn

for the symptoms of

gas bloot en dysphagia.

Of dysphagia.

Ja.

But as I say, this operation actually never even

worked. Just clean the lens.

There we go.

Pull this over like that, over there.

There's a little

gap missing there. We didn't cut

it the way it's been cut way before.

the diaphragm, relax the liver.

Otherwise you're not going to get

what size is this

tykron?

One.

I like using a thick material

because the thinner materials cut through the muscle.

You must use the thickest thing

that you can find.

So I'm using a tykron one

and that's the thickest thread I could find

on a 26mm needle.

I went through all the catalogues

of all the different companies

and this is a

CVO, cardiovascular

suture.

I actually found it in the

Therese theater.

In the early days, I used to use

Gore-Tex, but

I prefer the

braided suitje.

Weet jy, ek gaan stilmaken, weet jy,

soos skree.

A few minutes ago, I told to Piero that it was

tycoon number one, but he don't take

care about my opinion.

I don't believe a single word.

And sorry,

I got another question.

Perhaps the same

question that too many people

perform before, and

what's your opinion about

mesh use

in this procedure,

because I'm really afraid about it.

I

don't want,

very seldom or ever

use mesh. I think

if you want to

use mesh, you must know the next operation

is going to be a very difficult

Iver Lewis esophago gastectomy.

It doesn't help that

much to start off with the biological meshes don't work at all nothing and your polypropylene meshes

they you must just wait long enough they will complicate either with sepsis or erosion

and it's okay if you get away with it but the patient who has a complication

that is is an esophageal cripple for the rest of his life so i don't using mesh i think it's not

nie nodig, jy kan alweer dit, ek het eindelijk een paar jaar geleden vir die kongres, ek het, ek dink

oor 6 patiënts met intra-thoracic stommels, met een heel groot hiatus hernias, en ek het

heel duidelijk daar, ook met heel, heel groot hiatus hernias, jy kan alweer, as jy

dit soos dit, jy kan nie soos jou anterioor horizontaal, jy moet soos dit,

want dit is soos een dome van een tent, jy kan net dit neem, daar is meer dan

than enough tissue

and you can virtually always

get it closed. You get this

odd cases where they've had multiple

redo's

this is very hard, multiple

redo's and then the esophagus

is splinted, it's

rock hard and you can't close it.

Then you've got the problem that you

actually have to replace a part

of the diaphragm

with mesh to cover

the defect and those are the

only cases and they are few and far

between i maybe see one a year and i mean i do a lot of these cases it's very seldom that i need to

use mesh and every time i use mesh i know i'm probably going to be sorry that i did it so no

i don't like meshes i don't think you should use them well thank you i perfectly agree with you

because i i think it's also a danger very danger because yes i've seen some endoscopic procedure

with a mesh inside

the esophagus.

Ja, we see

them.

It's not the right place, I think.

No, it's not the right place.

But you know, I think if you speak to

any experienced esophageal surgeon,

they all agree,

stay away from mesh.

I mean, this is

very popular amongst

inexperienced

surgeons, but

But you must just have enough experience to realize what the terrible dangers are with mesh.

It's really, and I mean if you see the complications of mesh, as you know,

I've taken out meshes through the esophagus.

Let's just open this up a little bit there.

We'll clean that lens now.

So right up here Peter.

Blacker than Seblini.

Ah, yeah.

Right, there we go.

Right, clean the lens, please.

Right, nog net twee stekjes,

as ek wil. There we are, camera, please.

Thank you.

Trek jou nasogas

iets bykie terug. Just pull back

the nasogas stieke bit, please.

Nog bykie terug. That's it, thank you.

Ja, what we're going to do is to take

that fundus. There we are.

Fundus, put it over there.

Put it up over there.

En so.

Ek wil lekker spanning op my nek.

Maar nie die deur gaan afruk nie, ok?

Just checking.

The esophagus is slightly on the short side, but it'll be okay.

Alright.

Daar is aan die gang, daar is aan die.

So daar wel om is moord.

Ja, it's slipping out.

Now I'm happy.

Right, now let's go and look at the size of the atis,

because we closed it up rather blindly over there.

But according to my calculations, it should be okay.

Let's pick it up there.

Again, that one centimeter, eh?

One five millimeter and another five millimeter.

So it's a bit tight, but that's fine.

So one centimeter by endosophagus,

18, FG18 nasogastic tube.

This is our local, the Markade and magnesium sulfate.

There we are.

Good.

I think she's going to feel a bit better.

Yeah, everything is back to normal now.

Yeah.

um dj i want you to go into the camera the top here now what i do at the end of the procedure now

is we're going to aspirate don't kill it we're going to aspirate the nemothorax we just go

mid to the killer line second or third space you can actually hear it now you have to listen until

it stop sucking and then we do a chest x-ray in the recovery room to make sure that there's no

nie neemathorex,

en daar is niks op die

linker kant, dit was alleen op die rechter kant,

so daar, we

aspirate our neemathorex

with a verus needle,

excellent, really

masterpiece,

thank you,