COPAESCU 2

hello everyone and again we are grateful for the invitation to this outstanding event now

we are demonstrating a harvesting go for a terrace ligamentum in for a procedure of

of hiatal hernia repair after sleeve.

The harvesting of the teres ligamentum

should be carefully performed

as the entire structure to be able to resist

with a good nutrition and oxygenation

to be long enough to hang down the G-junction

and to protect and prevent especially the hiatal hernia recurrence,

especially in cases when the gastric sleeve has been performed before.

This is a brilliant procedure that has been described more than 50 years ago

by Professor Narbona in Spain, and it was abandoned for a long period of time.

And with the era of gastric sleeve, we were in a need to try to use natural structures

structures to help the G junction to stay inside of the abdomen. We harvest carefully as I just said the teres ligamentum always by the means of gestures using monopolar hook and by this with a very good visualization

we will see exactly which are the branches that are coming mainly from the liver but there are

some branches that are coming above from the diaphragm that we are going to treat them to

transect which is what is important is to keep up all the branches that are coming from the liver

the umbilical artery and vein that were used in the umbilicus cordus in the intrauterine life so

we try to do it as long as possible you see where the umbilicus is that means that we still have

some centimeters to dissect and I can tell you that this is never too much

when there is an extra length for the teres ligamentum after wrapping around

the GE junction and the inferior esophagus we can take down the rest but

But being short means that we cannot do the procedure.

This is why in the last two years of this experience, which is consistent, very consistent now,

as probably most of you know, we do perform a lot of bariatric surgery,

more than some cases per year, from the revisions.

as i said since two years ago we start the procedure with the harvesting of the teres

ligamentum because if there will not be a good quality of the teres ligamentum too short

with poor vascularization and there are arguments of considering that it will not be continued the

procedure we should go and the perf the patient is informed for another procedure naming here

including the change of the bariatric procedure to ruin my gastric bypass if

the gastroesophageal reflux is an issue and without heart and hernia repair only

Only with hiatal hernia repair we cannot control the symptoms. You see just on the back aspect of the main view the umbilicus.

We are approaching the ombilicus and now we can transect the vessels that are continuing down towards the inferior part of the abdominal wall and we are preparing for now the test of the vascularization of what we harvest.

because it is good to see the colors it is good to have the length but it should be a high quality

of the of ligament now we can concentrate to the last gestures of harvesting meaning that we need

to go as deep as possible to the origin of the teres ligamentum in order to have

a good mobilization of the ligamentum to the left beneath the left liver lobe

toward the G junction and surrounding and the principle of this operation is as I will touch

again the subject is when the diaphragm will go down with the air intake in the lungs the

the left liver lobe will go down and will pull down the teres ligamentum

and with it the G-junction, which is very wise.

I mean, the idea of Professor Narbona is wonderful.

We can encounter now the adhesions that are developed after surgery

surgery, you know that laparoscopic surgery is very limited in this respect, and this

is demonstrating our procedure today, almost no additions.

What we need to know is not only the anatomy at the site of the GE junction, but also we

We need the entire shape of the stomach to be revealed.

Because in gastroesophageal reflux disease, after sleeve, we are performing a lot of radiological studies, PH-metry, manometry.

The morphological and functional investigations should eliminate any disturbance of the gastric component in order to address the hiatal hernia and the upper pole involved in this reflux only.

and we do this dissection starting from the antrum because here at the antrum we can see

easy the delineation between the osteoarthritis and the pancreas capsule, the mesocolon, transverse mesocolon,

and we will understand better the anatomy

and in case that there is a twist

or an impairment of the gastric emptying

we need to fix it

because otherwise we will create another obstruction

above the pre-existing not revealed obstruction

However, in this case, it was no information that there is a situation, an obstructive situation, and you can see from outside that the stomach is uniform.

It is enlarged as it was at the end of the previously performed sleeve because in this case we have three years from the initial operation, but the therapeutic outcome is very good.

The patient is BMI 26. We have a wonderful control of the comorbidities that were listed before for the surgery and there is no need to touch the metabolic component to do a rest leave or to think about some other procedure to support the potential waste.

regain but only the reflux we said the Mr. score of 38 in this case we know

also that there is a hiatal hernia in this respect and this is the issue of

performing an extensive dissection from down to up to see exactly to understand

exactly the structure of the stomach it can be seen nicely a thread that it's

part of it is part of our procedure of over swing entirely from the angle of

his two pillars this step align and this is the stitch that you are going to see

better after we will be able to dissect clearly the aspect of the stomach and the entire

length of the stepper line is covered with healthy tissue and this is limiting the

the adhesions that cannot be controlled after the surgery.

And some of these adhesions are responsible for a retraction

and a twisting component of the stomach,

which is significantly influencing the emptying

and of course D-reflux, potentially a reflexogenic situation.

And slowly we go up, we see nicely the pancreas

and the last adhesions in the upper third of the stomach.

And we should approach again the left cruz

And the diaphragmatic cruz is our landmark to start the dissection at the level of the hiatus.

we try to free up all the additions because otherwise it will be a twisting stomach at the

end of the surgery and we would like to delineate everything in order to be sure that the new

new position of the stomach will never affect the flow of the food and the liquids ingested by the

patient. Moreover, when we will be ready with the dissection from the G-junction to the pylorus,

we will be able to appreciate the volume of the stomach and by inserting a nasogastric tube

and introducing of the air blowing up the stomach we will be able to see exactly what's the volume

of the stomach and then this is a good note for the future because we have the

possibility of rendering radiologically the volume of the stomach but if there

are additions inside of the stomach it's difficult to consider exactly the volume

Now we will know better and try to predict the future.

The gastrohepatic ligament is opening up the bursa mentalis on its medial part

And we clearly see now the right cruz, which is carefully dissected around the G-junction in order to dissect and free up the inferior esophagus.

was the first rule of the demister antireflux attitude and the phrenohesophageal membrane

is stretched and of course we need to transect it of the insertion to the diaphragm and here

Here we are approaching the left aspect of the phrenoesophageal membrane to the right of the image and slowly we are getting into the inferior mediastinum.

and we can use different instruments for this we love the hook because this is using only limited

quantity of energy with cut or blend and the injury to the structures that we are dissecting

now should be very limited and we don't want a sealing process here we want only a dissection

to see exactly the left cruz that it was revealed at the neighboring of the ligamentum marquatum

pre-aortic fascia and then we hang down the G-junction with by means of gauze which is a

cotton white and soft material anytime you can find it and the grasper handled by one of the

the aides in the OR, the surgeons in the team can grasp down and present the entire area.

Now we can approach from the left the hiatus and the gastrophrenic ligament is going to be transected having a clear evidence of the inferior esophagus

and the reflection of the upper component of the phrenoesophageal membrane.

You see the white one that is continuing and covering the left cruz.

And slowly the dissection is surrounding the esophagus.

And we are seeing now clearly the gestures of transecting the last part of the Lymer-Bretelli membrane, the phrenoesophageal membrane.

By dissecting completely the esophagus at this level, including the transection of the upper component of the phrenoesophageal membrane, which is exactly now demonstrated, we are in the chest.

And we are in the posterior mediastinum, freeing up now the esophagus, which will be completely taking down for 3-4 cm, sometimes even more, which is essential for the success of a hiatal hernia repair.

the need of the staying in abdomen under the continuous positive pressure of the peritoneal cavity of the inferior esophageal sphincter.

We see the vagus nerve. I think you noticed that I showed you exactly the right one and we will see the anterior one when there will be time deep in the mediastinum.

we saw for a second the plura, the right-sided mediastinal plura and we

continue to mobilize the you see deep the white one and the surrounding

dissection is now demonstrating I mean the dissection could succeed what is

demonstrated now a lengthening of the inferior intra-abdominal part inferior

esophagus with its intra-abdominal part for about five centimeters and now hello

hello are you talking to me hello I'm Chichetti from Urbino I'm hearing only

now I'm hearing only now I am Chichetti from Urbino do you hear me I can hear

I hear you very well. I am Cattelin Copoescu from Bucharest. We are demonstrating the hiatal hernia repair.

Hello. What's the clinical problem in this case? I saw some adhesion and perhaps previously gastric surgery for bariatric surgery.

Yes, it was a gastric sleeve for bariatric surgery.

The only complaint in this patient was gastroesophageal reflux disease with a demister score of 38 with a hiatal hernia that has been demonstrated by the CT, endoscopy and radiology.

and now we are fixing the hiatal hernia

and then we will reinforce the G-junction

with the teres ligamentum.

Yes, okay, I know.

Okay?

Okay.

Thank you for asking the question, Professor.

Okay, is it clear, the image?

I would like to send it to you.

Yes, yes, yes.

It's clear.

Okay, thank you very much.

What we usually use here is the crossing stitch with non-resorbable material, polypropylene monofilament.

And because there is a significant risk of migration of the G-junction after fixing the hiatal hernia without being able to do a fund application.

Because after gastric sleeve, you will never be able to do a Nissan Rossetti or a toupee or any kind of fund application because we don't have the fundus there.

So, we need to think about something else to hang down continuously the G-junction.

And we have two components in this respect when we are repairing the hiatal hernia, which is mandatory.

Because now you can see that we have a good positioning of the G-junction.

however now the co2 is rising up the pressure inside of the esophagus inside of the abdomen

so the diaphragm is up when you will take out the co2 the diaphragm will go down and the g

junction will go up so the g junction will be exactly in the chest so we have two components

to keep up the G junction inside one is the teres ligamentum that we harvested

before and now we are checking if the vascularization of the teres ligamentum

is correct you see the vascularization that is getting from the origin slowly

look at the gray area I'm gonna look behind the stomach and it's mandatory to see the blood that

is reaching at the end of the teres ligamentum otherwise we will have a piece of meat that will

will you see clearly we can demonstrate the presence of the blood there and this is very

good for the nutrition and oxygenation of the teres ligamentum so we have a well harvested

ligament before I was mentioning that we are looking to the lengths of the

ligament and now we are looking to the vascularization that means that we can

continue with the procedure and we will wrap around the teres ligamentum at

at least in six points at the level of the inferior esophagus

using 3-0 monofilament stitches

without penetrating in the aluminum of the gut

and these gestures will be nicely performed

being sure that we are not harming anything

anything the second aid because the first aid is the camera holder the second aid is lifting to the

left the teres ligamentum and we try to get in with the 45 degrees camera to get deep there to

to see behind where the knot is going to be fixed.

And by putting around the teres ligamentum,

we will consolidate the G-junction to the inferior aspect of the liver.

And as I said before, when the patient will take a deep breath,

the liver will go down.

the diaphragm will go down of course the first the liver will go down and will pull down the

teres ligamentum and this is pulling down the g-junction otherwise without this component

when we take a deep breath i mean the patient after the surgery the diaphragm is going down

and the g-junction will be in the chest in in seconds and in time we encountered in all the

bariatric procedures a migration in the chest this is not exclusively about gastric sleeve

yes we studied more the gastric sleeve in the last years but this is the same for gastric bypass

It is true that gastric bypass is using the alimentary loop that is hanging down the gastric pouch and the risk of migration is less.

But whenever we have an enlargement of the hiatus, with the hiatal hernia, the presence of the G-junction in the chest is only a matter of time.

So, this type of procedure using our anatomy and our components, not foreign bodies, it's one of the solutions that we are considering for these very patients.

The second one will be the reconstruction of the gastroesophageal membrane and you will see at the end of this procedure that we need to complete the fixation of the esophagus to the diaphragm with some stitches surrounding it.

I am aware about the different movements of the diaphragm and the esophagus when we swallow and that it is not recommended to have a rigid connection between the esophagus and the diaphragm because they do encounter differently the movements themselves.

But on the other side, you have to know that this connection is a very thin one, it will be completed by the scarring at this level and this is going to edit what we have originally, the membrane.

This is what I am referring about. Only the anterior aspects of the esophagus and the insertion of the phrenoesophageal membrane, that is at 11 hours.

there will be another one at two o'clock and one it was already at six o'clock when we passed the

stitch at the posterior approximation so there will be not there will not be a rigid connection

but this is preventing at least for some days before the scarring process is

starting at the side will keep the g-junction inside of the chest otherwise when the co2 will

be out the diaphragm will go down and the entire procedure of approximating the crura will not be

efficient for the new positioning of the stomach.

We have only some stitches to end the procedure which is completing now the wrapping of the

the teres ligamentum above the G-junction, around the inferior esophagus, and the procedure

is almost ready.

I tried to offer you as many explanations I considered that are necessary, but I will

stop with my talk, not to exaggerate, and I will be ready to answer to any of your questions.

Yes, it's very interesting, because this kind of surgery, you try to do a synthesis of

of physiologic breath, physiologic swallow and I can see that there are 2 cm of esophagus

in abdomen cavity, and so the intra-abdominal cavity can act in the end of the esophagus

and preventing the reflux.

Exactly, professor.

That is exactly what is the rationale of this.

It may be complex, but I tried to demonstrate clearly that it's a pretty straightforward procedure.

It is not complicated from the technical point of view procedure.

Only you need some patience to harvest properly.

And now you see that we are again introducing the ICG to see if there is an additional information.

And now we are looking also for the washout because it is not only the arterial component important, but also the venous component.

Because if we don't have a good washout because the venous system is not efficient the tissue will die. So by this we noticed that the inferior part of the teres ligamentum after 20 minutes at least is still colored.

that means that the inferior part is not nicely washed out that means that maybe the last part of

the of the teres ligamentum i mean the distal part which is a little bit too excessive in lengths

can be translated there is no need for it and this is the last stitch I told you that it's

trying to reconstruct the physiological element that we are taking down whenever we dissect the

the G-junction for the hiatal hernia repair in open or in laparoscopic or robotic surgery.

And you know very well, Professor, that this is something mandatory for years,

and probably we need to think more about the physiological issue to try to rescue the function.

This is the last part which was not washing out nicely. We saw this with ICG and we take it out. Then we will place a drainage tube and the liver retractor will be taken down and when the hemostasis is demonstrated good, we are happy.

this is the demonstration that we did from Bucharest and we are again happy

and grateful for the invitation professor