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

Thank you.

Do we have any more contact?

Yes.

Good day.

To enjoy again once more.

Right.

This is a patient who had a Nissen 15 years ago,

but she's been on PPIs now for more than the last 10 years.

She was different also than somewhere else,

different place from the previous patient,

but on the endoscopy she had very much the same configuration so we'll see what we find inside

here always a nice little surprise right so this will be inside built okay let's go there we go

it's the rod okay there we are right let's have a look and see what we can find here

of that over there

hasn't got much adhesions

that's lovely

that helps us a bit

now you see again

this is the nissen

my shame

sorry for laughing

different hospital

maybe same surgeon

are we a pardon

when she was

maybe the same surgeon

no different surgeon

cruise it's a cruise there all right let's have a look on that side shame oh my goodness

this is stomach this is not esophagus again you can see where this look where it comes there's

a fatty pad there's the fundus look where the nissen comes around completely different

the wrong configuration.

You said that this was

15 years ago.

Is there any possibility

to time

when the actual recurrence

happened?

Was it an aptitude?

No.

No, there was no incident.

It just gradually started.

And what often happens

if these people get

parasophageal hernias they can often be asymptomatic for years before they

present because often they then present by the time that they present they've

got a total intrathoracic stomach stomach so it's very difficult to put a

time frame on on the actual recurrence right let's have a look here this is the

measly little nissen, can you see it's around the stomach again, yes it's very clear, now

I'm going to put in stitches.

Okay.

I'm going to put in a stitch.

That's kind of my girlfriend.

Yeah.

All right, let's get this going.

Is this still on the line, DJ?

I think it's still on the line.

Okay.

Look here.

That's a three-meter long journey, eh?

It's a little bit like that.

Let's put this one back again.

All right.

Get the liver retracting to a better position.

This liver retracting is much better than the previous one.

Muscles and the heart.

Ayn, being 15 years, I would say that the adhesions are quite flimsy.

Not that bad, you know?

Yes, not that bad.

Very little adhesions, yeah.

But I think it's also probably because very little was done.

It's better?

Most probably.

most probably

but it's terrible when you're coming

and it looks like there's been a hand grenade

in the abdomen that can be

very difficult in those patients

and the little

one being done wrongly

yeah right we'll see

what that looks like once we've done the operation

right here's our fundus

let's put it over there

specific landmark where

to put the floppy nissen

sin? Well, yeah. It's difficult to show in these cases. I'm just going to try and get

some nice, healthy stomach here. What I'm doing now, I'm actually coaxing the stomach

around so that the bad part that was loosened is now lying down on the inside of the nissen.

You see where the previous nissen is. I'll fold it and put it on the inside. That can

also come loose not not affecting i should be all right

now if we look at this this is the esophagus yeah where these little vessels are transverse

over there that's where your zed line is and the stitch on this over was uh is uh

full thickness or just the muscular like just just muscle and anterior vagus nerve

I try not to go through otherwise these sutures can sometimes slough out into the esophagus so

we've got the real esophagus let's go and have a look at the size again five millimeter five

millimeter five millimeter to one centimeter plus an 18 nasogastric tube in it you get quite

a significant amount of people that actually have quite a bit of dysphagia afterwards and it takes

them sometimes a day or two or three or five or ten or twenty before they can swallow properly

but you have to persist if you come and sit take out stitches so that they can swallow easy

you're going to do a redo next year on a parasol earlier right now this patient also also got

gallstones so we're going to do a you can see how the liver has been pushed there or engorged

right now we're going to do the cholecystectomy and what i do here

i don't use the same ports anymore i've given up on that just going to deflate the abdomen

I don't work through the same ports because they they're not placed in a very good position

Right here. Let's go.

I normally just use the hook when I do a cholecystectomy,

but we've got the Thunderbeats.

Sorry, Hein, we don't have the inside view.

Have you not got the inside view?

I need to go around.

Go around.

Is that the Thunderbeats?

Yeah.

Okay.

Yeah, I'm using the Thunderbeats because it's...

I normally just use a hook,

but the Thunderbeats has been connected

it because we did theitis hernia so we might as well use it it's a luxury yeah you can see

the cystic duct coming out there's the cystic artery so there's our critical view five millimeter

clips forget what we're going to do next time we're going to have to do this again tomorrow

Let me just try to cut it a little bit.

It's small.

See, it's on the valves.

I'll try one cut a little bit more.

I'm probably going to cut off the whole cystic now.

See, there is the lumen.

That's too small.

more yeah we won't get the catheter into that little lumen so we're not going to do a gram

what was the reason to do a cholangiogram i routinely do cholangiograms it's just to

delineate your anatomy and then you know you're cutting off the right stuff and this is a very

small little cystic duct but normally it's not a big deal it goes quite easily it takes extra

two three minutes and then you've got a big safety factor built in

I'm not going to go that far, I'm going to come back a little bit.

I'm ready to pull my belt to your heart.

There we go.

I'm going to come out with you now.

That's fine.

Can I see your lens?

It's the cystic duct coming there, and there's the hepatic duct over there.

Both of them.

Can I ask this?

Max, can you lend us yours?

There we are.

Local?

Mm-mm.

I'll be back.

Local?

And there are ports come out.

Oh, I've got one of you loose.

There's that one.

There we are.

Yeah. Let me introduce my team, DJ. This is Dr. Truter. She's a surgeon that works with me. And we often spend some time together in the theater, of course. Right. And this is Dr. Rabe. Of course, she's my camera person. She identifies as a woman.

but she's my camera person and she's been working with me for how many years now

nine years and she also helps me with my endoscopies during the day where she gives

the anesthetics and then yeah sister from the back who's hiding behind a mask uh one of the

nice chicks i have yeah peter she's a she actually worked with me as a as a scrub nurse and then

then became the theater matron,

and then she went, amongst other things, into business.

And I actually lured her back to help me,

and she's part-time just coming in for my theater lists three times a week.

So this is my – unfortunately, I don't have a female anesthetist,

of course, which I'm wishing for, but it'll still happen, I'm sure.

Right.

Right. Well, that's my team that I'm working with.

Right.

That's my team that I'm working with.

Right. Excellent.

Congratulations to all of you.

I believe this was

the last case, isn't it?

This was the last case, yes.

Okay. Thanks, Willie. I enjoyed

that. I mean, in a few hours,

you made excellent cases

and everything. I don't know whether

you had open eyes. I don't know.

because behind the glasses

I can't see

but maybe you go so fast

all of you also

your assistants, your doctors

they go so nicely

and so automatic

I don't know whether it was a robot

robot body surgery

we're a good team

we work together regularly

thanks Peter

thank you for everybody watching

I'll speak to you tonight

night, Peter. Hopefully

if there's electricity, eh?

I know, I know.

Listen, sorry that

Italy lost to South Africa last

weekend.

Okay, Peter,

keep well. I'll speak

to you again. Ciao, ciao.

Right, and looking forward to see you again.

See you, bye-bye.

Tot ziens.

That's it.