Laparoscopic Paraesophageal Hernia Repair
- Portal Placement
- Place Left Side Instrument Trochar
- Retract left lateral segment of liver
- Place Second/Third Trochars Completing Triangle
- Mobilize Hernia Sac from Crus
- Dissect Gastro-Hepatic Ligament
- Dissect Hernia Sac off Left Crus
- Dissect Hernia Sac off Right Crus
- Dissect Posterior Aspect of Sac
- Identify Posterior vagus
- Transect Short Gastric Arteries
- Dissect Hernia Sac from Greater Curve of Stomach
- Expose Esophagus Cephalad to Sac and Identify Ant. Vagus N.
- Separate Stomach from Hernia Sac
- Dissect Hernia Sac from Stomach Via Inner Sac
- Excision of Hernia Sac
- Continue Hernia Sac Dissection of Stomach
- Dissect Lesser Curvature of Stomach
- Dissection of GE Junction and Esophagus
- Further Mobilization of the Esophagus
- Dissect Mediastinal Pleura Tissue from Spine/Aorta
- Place Blue Loops around GE Junction
- Continue Dissection of Posterior Hernia Sac from Stomach
- Dissect Lower End of Left Crus
- Crural Closure
- Combined Extra and Intracorporeal Knotting Technique
- Ensure Esophagus Dissected and Lengthened
- Toupet Fundoplication and Gastropexy
- Align Short Gastric Arteries
- Posterior Gastropexy
- Excision of Suspected Benign Mass
- Port Site Closure
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Hi I'm Dr. David Rattner we're going to repair a paraesophageal hernia today laparoscopically in an 85- year old woman whose main complaint is dysphasia. It's a very complex case of a lot of preoperative evaluation she definitely has an esophageal motility disorder has not really responded very well to the usual treatments and she also hasn't responded to Botox injections or other things that one might do to treat achalasia or dysmotility there's a sense among her referring physicians and I agree with it that there's some mechanical component to her dysphagia caused by the paraesophageal hernia so we're going to repair this laparoscopically and I hope that she has a good response to it.
So what we’ll do is we’ll get all things set up laparoscopically, expose the Hiatus and then we'll take down the hernia sac separating the parietal peritoneum from the mediastinal pleura once we find out whether we can reduce her stomach without any tension we’ll trim away the hernia sack, repair the hiatus and in her case I may do the most minimal of fundoplications, more of a gastropexy than a fundoplication per se since she's got such severe dysphagia I would really just want to straighten things out anatomically and leave it at that if she has some reflux afterwards we’ll treat that medically.
Let's have a knife please. So one of the important things about doing a paraesophageal hernia or any esophageal case where you going to be high up is to not put your trocar are in the umbilicus, put it left and midline and cephalad to the umbilicus. Everybody's different size and shape so it needs to be individualized. I don't think there's one formula that fits all patients. Okay a little bit more reverse please. That’s her colon. Let’s put yours in first because you can take a grasper and push it down and then get this in better. Let’s have a 12 please. Let’s put the next light in your hands.
While you're waiting for that she doesn't have a 12 millimeter trocar. Why don’t you take this, take a valve. I'll have a knife, please. This will have to work. Should be prefect. Okay, let’s have the alien now please. And then the liver retractor. Lift that liver up with your grasper. That’s interesting. Don’t know what that is. It’s interesting, drop that out of there. I don't know what it is either but I think we could take it out a little harmonic scalpel. Alright let’s fix our main problem to fix your main problem first let's do that at the end okay, because think that it would be a mistake if we did that and had a problem. Knife to Steven. Just below the rib. You want to set up your trocars. So if there's a triangle between the optical trocar and the one with which he’s going to operate with his right and left hand.
Let’s see how much of this comes down first. Tiana grab the discus weigh. Sure absolutely. Let’s pull this this way. Alright harmonic please, we don’t even need that, we’re going to open this gastropathic ligament first. Can the table go any lower or not. Steven I want you to grab right here, that’s good right here, thank you. We have- Plank grasper to Steven. The vagal branches are going to be running up in here probably, it's hard to see them yeah but you're right it's probably not whites at once you switch your grasper for now. Grab fat out they're coming up closer with the camera and grab it right there, that's perfect okay. See what you do is you want to take this fold of tissue. Right into the, yea. That's excellent that's a great move there.
Okay just a little bit closer, okay good that’s what we want. Inside the sac-try to leave the muscle where God put it. Okay so usually you can get about 270 degrees around here. Okay why don’t you grab right here. Okay that’s outstanding. I’m just going to gently peel that off until we get a good plane going here. I’m going to try to keep this hemostasis for as long as possible. That’s nice, that’s a good sac. The muscle fibers all the way down here even. Let's Chris to trade let's trade places here and I want you to grab this and start. Pull this down, well maybe not yet. We’re not quite there yet, Steve. Actually, probably could die from this. That muscle. It's crus, it’s just very frayed and has come down onto the sac here. Hold that back from whence it came. It’s coming out through here. Just a smidge closer. Pull that stuff down over here so we can see where going here. That’s good there.
So if you increase muscle tone or is that just an inevitable consequence of-? I'm fine with it as there's there's nothing in between there, there’s nothing there so I'm okay with that. Let’s get that little band right here. She’s fragile. Pull up. Pull up and scrub the stomach and pull that down just so you can get that. That’s excellent. So let's pull on that, look down at 6:00 while we’re there let’s grab right down there at 4 on that. I'm would would grab, yea that's good there because I have to dissect that, even that. I just need to be able to see the margin of the crus right now without getting into the stomach so I think this is it right here. Pull right there.
So this hernia sac is going to come into the stomach pretty shortly there so let's look back here and stay on the muscle. Come in closer, please. The hernia sac is on the crus. Well the hernia sac is the peritoneum and pleura. Right and that’s why when you divide it you see the muscle and the crus. Right exactly. Because right now you’re dividing peritoneal sac and peritoneum. And that's my stomach is coming in right here. Come through this right here, So I can come in here without hurting the stomach hopefully. It’s a short gastric coming shortly. So this little band right here has got to go. This may be a short gastric here so if you just gently hold the stomach, rotate it as much towards the patient’s right, that’s good stop right there, doesn't have to be hard.
Alright let’s stop there for a second and let’s go over to the right side. What stopped there for a second. Let's go over to the right side. Let’s grab the hernia sac way up in here, grab that, come in closer with the camera. That’s good, let’s get that on a stretch here, good, excellent. Just a little bit closer if you could. Her muscle is just pathetic, pale and weakness.
Coming down here. Just gonna pull the stomach down here so we can see this better. I’m going to hand it to you why don’t you take this. Good that’s good there. Here, just peel a loaf of it. Let’s just look way down in this corner here and see what we can see. So far .Get rid of that. Those white branches are probably vagus branches. That’s exactly right, yes. The vessel right in there, coming off. Got another crus, right where I’m pushing, should be right through there. I’m not sure, oh there it is. That’s just experience, I didn’t see it, I just knew it, it’s about where it should be. So again, you just try to dissect the crus themselves, the sack themselves, and not worry about all the other structures, it’s sort of like addition by subtraction, once you get those things sorted out, then you can figure out where the esophagus is, vagus and all that.
Okay let’s look right up this side right here, so that should be takeable. Right here. Back of the esophagus right here. Let’s go way up in here and see if this-I didn’t see that same peritoneal and hernia sac because you’re inside the hernia sac. No, no we’re not this is the peritoneal hernia sac right there, this is just mediastinal stuff. I’m just looking for the posterior vagus which I don’t quite see it. I think this could be it running down the aorta and coming up here. That is it in fact. That’s it right there. Interesting how it doesn’t really join the body and the esophagus. Not here it doesn’t but this is it right here. That’s important. Okay, this is all gradual, up in here That can all go out here. That’s nothing. So the next thing we have to do, is take down the short gastrics. Let’s Stop here Steve, let go. What we have to do is take off the short gastrics and take the hernia sac off. Okay, so let’s grab right about here. Are you going to excise the hernia sac? I’m going to excise a whole lot of it. Let’ just pull this down a little bit. Install right here.
The nice thing is is if you have a hernia this big, the short gastrics are long, they’re not short. Okay, if you wanna be that way be that way , see if I care. Question is how we’re going to get this darn curd back together, that’s gonna be the challenge. Look here. Let’s move up the greater curve now, okay. Let go of what you’re holding. Start working our way up here. You can grab the stomach right here for me. Just gently pull down. Tell me this is not going to want to come down freely, I’m going to be very unhappy. It never seems to. Okay why don’t you hold the sac right here, usually once you take the sac up, okay I want you to pull it out toward the left upper quadrant. Okay good, let’s do that. That’s like two layers, I’m going to peel the sac off the fundus of the stomach and find out where the GE junction is. All that stuff will have to go as well. So what you’re dividing here,with the harmonic is… The hernia sac. Let’s get this anterior side. It’s very confusing.
So you don’t always dissect outside the sac? No I’ve dissected outside the sac about as much as I can, so now I’ve got to get the sac off the stomach in order to free it here. Probably the stomach is twisted in here by the sack so you can’t totally restore the normal anatomy until you get rid of the sac. See you just want to hold it, back here, so grab, actually you know what let’s just keep going where you are, I like where you are first, we’ll do that layer first. Getting closer. So the sac actually maintains the organo-Exactly, exactly right. Check this first. So you think you’re through the posterior sac there. Yes that’s the posterior part of the sac. And you’re cutting into it, so the mediastinum is behind you. Yes, this is where we dissected before, see. Right that’s mediastinum. Right so that makes this pleura or peritoneum. The ones I’ve seen where you see a pleura you can sorta see a white line, you know. Yea, for sure.
See that, is the inside of this, let’s go back down here, stay where you are for a second, pull the camera back, let’s look down here, let’s free up the rest of the fundus, the posterior part of the sac. Free the fundus from the sac, yea. So I think everything, is crossing the crus right here should be able to go. So that’s that side of it. So you hold on to what you got for a second, because if I bring this down here, so here’s the edge of the sac, here’s the anterior vagus right there, huh, interesting. This is gradoo that can go. Nice, that’s actually not bad of a PDH, the one I did last week with Anna was far worse, up near the carotid. Just have to be careful about the esophageal wall, it sneaks in on you pretty quickly. Move the scoping just a little bit farther please. Get all the gory stuff up in here.
I thought you don’t need to drop the scope for this? What’s that? I thought you don’t need to drop the scope for this? Most times no. Okay. I mean we’re all the way up here to the aortic arch? You can feel the arch? Up there. Let’s pull back for a second. Pull back on the scope for a second. Okay, why don’t you grab right here. Okay that’s good, like that. Okay, good. Let me see this for a moment. Bring the scoping closer please, okay that’s good there. Let’s get this separated off the esophagus here. Okay so that is stomach down here, all right?
Alright, this is on the stomach, we can definitely take this part of the sac off, without hurting the vagus. So once you’ve gotten the sac off of the mediastinum, step 2 is actually to separate the stomach from the sac? Yea, I like to, because I don’t think you can accurately place your sutures without. Yea, because you can’t see the GI junction. Right. So why don’t you regrab right here. That’s good there, so we can see that pretty clearly, if you agree with me.
There’s not nearly enough attention to this step in the textbooks. Yea I mean the diagram says you just whack the sac off, ezy peezy. Yea they say dissect the sac but they don’t say, or they say reduce the sac, but it’s not just reduction, it’s separation of the sac. You have to know where this stomach stops and where the sac begins. That’s the hard part. Because it’s actually two, you have to be outside the sac to get it off the mediastinum and you’re inside the sac to get it off the mediastinum. Yea well usually it splits into two layers, which is what I’ve done here and I look for this areolar tissue plane to try and help me here. What do you mean it splits into two here? Well see, this is the anterior layer. The posterior layer we already divided. Oh yea. This is vagus right here, right here again, so that means that all the rest of it we could take. So that stuff could go. Isn’t there one layer that goes radially around the esophagus. It seems like it’s two, it seems to me there’s often two. You have to sort of split the two layers to find, if you just stay in one it's confusing you can find yourself cutting right in. Well you’re cutting there just seems like one layer. No, that's because I already took one, I think, okay.
And the other thing is it's not uncommon to injure the anterior vagus as you go through this because you can't find it and I see it. Super Bellsy’s sac, like you can’t even see Bellsy’s there. So I should now be able to come underneath all this here because there's the GE Junction right where this hernia sac is attached right? The GE junction should be right there. Right, sure. That should be posterior, anterior vagus then, right? Because-No, because it’s attached to the sac and we’re flipping it all over the place. That’s part of the issue right now. I thought the anterior vagus was supposed to go into Bellsy’s. Which I have in my hand. So you’ve already taken Bellsy’s.
So I’m coming off almost across the midline onto the lesser curvature. Yea. Back up just a touch here. Bellsy’s is usually around the top of the GE junction. Bellsy’s is in the angle between the fundus and esophagus on the left side, but now since I’ve taken it off, it’s in the hernia sac and I’ve rotated it. But usually it’s on the anatomical left. That’s correct. Like the angle of His. That’s correct. Let’s see if I can avoid that vessel, take more of this stuff off.
Patient has impaired gallbladder motility. What are you holding right now? Holding the stomach. Why don’t you grab right here? Okay, grab the sac right here, see if I can take it out without getting into the muscles right here. They may, there’s been studies, pro and con actually. I don’t make a big deal out of it. Just take the stomach out over this way. So you can see we pretty much cleared the whole GE junction now. So what are we going to do, so the vagus has got to be heading back into the lesser curve right? That's where the nerve latter j are.. So why don’t you grab right here. Right there.
Okay put it on stretch and see the vagus I think it's got to be turning. This is all stuff from the sac, back up just a touch. Should be able to chop all this off right over to the vagus. The vagus has got to turn back into the lesser curve, okay. So this should all be able to go. The latter J should go into the pylorus, right? Right, antrum and pylorus. So it runs along the lesser curvature and lesser curvature fat. Taking a fairly generous distance away from it, got to preserve it. There’s no way we can go to here because this goes to nowhere. Okay that's the hernia sac. Let's see what we got here.
Go around. Twist the base. Pull that a little bit. Can I have that harmonic please? So we have the anterior half of the sac, we didn’t really do much with the posterior yet, which is right here. So let’s take there very little stringy things and get rid of them coming closer. Where is sac and where isn’t sac, where’s the posterior vagus now? I thought it was going to be right down there, somewhere. Oh that looks like it right down there. Very suspicious. Very suspicious. But this is you know what I think it's all the way out here see this coming off the aorta it's all the way out here. Jeez. So it’s easy to bag. Let’s see if we can free this up in here a little bit. I think it might give us...After all that, I think this is just mediastinal, I don’t think this is anything significant I think the hernia sac is up here. The sac is up in front of us here. See there’s the aorta right here and then the view.
Okay, let’s look at this stuff here. This is always bloody back here before I rip this. Let’s see if this stuff can go right here, if I can maneuver my way in. Come on, baby. There we go. Good. Let’s just go up in here. What is this right here? Where’s her esophagus in all this? Turn it again. There we go. So there’s the anterior vagus right there, here’s posterior vagus. Esophagus is right here, I believe. You can go around here, pull it back a bit and let’s see what we got.
Coming closer, let’s see what is this right here? It’s just the posterior vagus. This is what we’re seeing is posterior vagus. Your esophagus is right here. All this excess tissue, it’s in the way. Isn’t that posterior vagus there? That’s posterior vagus. This is posterior vagus right there and we got this other gradoo that’s sort of leftover hernia sac stuff here. And then we’ve got this fat on the lesser curve. Pull back just a bit. As you can see that’s all this stuff here it’s very bloody and we don’t really want to deal with it if you don't have to and then this thing right up in here is this lipoma of the GE junction, come in closer please, which is almost always there and it's always a pain in the ass. This thing right here up in here. And it’s always like posterior-And it always sort of interdigitates with the esophageal muscle. Yea. And it’s usually 8 o’clock on the esophagus. It’s this right up in here, that I’m stuck on. That may be another contribution to the posterior vagus, right? Yea that’s what I’m thinking, because it, I mean I was just reading this whole-Let’s just look up in here, keep following my grasper for a bit.
I think the main body of the esophagus is actually over on the other side of this. It's right there so that’s the vagus. This is spine actually, not aorta, right? I think we need to, see this purplish stuff here? I think if we divide that we’ll get a little extra mobility. Yea it’s been held there. The aorta’s on the other side of the spine. Why is the aorta in the spine back there? This is spine right here, I think. It’s hard. Plura’s sliding back and forth across. The aorta’s on the other side, on the left side of the spine, right? Left side the vertebral column last time I checked. Yes? I don’t know for sure I just mean like can you actually see it pulsing in there? I can't see it pulsing here because I'm looking at it I'm looking at things from the wrong side but it should be down in that groove right in there. See I think that’s all we’re going to do here, I mean. Or we’re asking for trouble.
Okay let's get around the esophagus here and get the blue thing in. Grab that and just lift up from that. I see some sac back here to deal with. Okay I can see the pleura fine. Let’s look on the other side here. I’m just going to have the blue thing here. Oh great catch. Let’s put it down towards the fume there. Okay, the loop please. I can’t get the fat out of the way but I can actually try to- Why don’t you grab the back one, grab that one. Let's put them in front of the esophagus. Usually I make the X over here that's part of my problem. Okay good. Got it.
Okay now pull the stomach down through the loop and pull it towards the feet and get this up as high as possible. Let me see if I can get that, close to that serosal tear. Come in closer with the camera. I don’t think so. I think you’re fine. And even if you did I think we can fix it, so don’t sweat it. Alright let’s have a tooth grasper to Steven, please. Grab these two, come in closer. You’ll do much better if you're in a tight like that, yea. So what happens, if you can lift that up and over.
How do things look back here? Get this extra piece of garbage to trim away except that we don’t know where the vagus is really running through that. I think you can actually see that vagus like that right there. I’m not sure that's really it because I think it's pretty close I think it actually doesn’t fold and it comes back in. I think it loops. I think we got our, yea. I think we have the curro. Let's see once we close the core this'll look a whole lot better. I going to want to take this a little bit of this stuff down right here. Not too much of it though. So left gastric artery pretty close by. Okay do you have the zero ethomine next?
Let's just look at the left crus on the left side for a minute. You can let go of that for a minute. Can I use a blank grasper there? Yea maybe a blank grasper, let’s just look at this little area over here. See this thing right here, I want to get this bottom into the crus fixed. You have to be careful because the splenic artery sometimes gets pulled up into this. It doesn’t seem like it would be a problem but it actually, I learned the hard way. That's a piece of stomach right? Where is it?
All right let’s come in closer so I can see better. So this little layer can go, right here, safely. The splenic artery is more in there while the spleen is in the chest? No, but you know what happens? Because it’s so curly cuey, I mean it can sort of just curl up and unexpectedly you find it. The other thing is there’s, sometimes there’s a, let’s take this, sometimes there's a phrenic artery coming off the splenic that runs right alongside that crus and if it starts bleeding it's just real bugger to stop it. See what did I tell you there's a big vessel right underneath there. Write a book of lessons I have learned the hard way.
Let’s push this stuff up off the crus just so I can get this the bottom off that crus and get this first stitch in correctly this is the area I'm looking at, right here. Let’s see if I put a stitch in there, just to be safe. Right, okay good. So you need to just push up here, that's what I want let's look over the top of grasper. Okay. So there’s not much more to get, I don’t think. Let’s try the tooth grasper on that loop and if that gets us good exposure. These first couple core stitches will be hard and the rest will be much better. Actually hold the two blues right now. Exactly, just try to hold-Oh right, okay got it. Okay that’s excellent. Okay, so that happens if you lift that up and over. And we see, yes. Okay stitch to me please. The aorta right there, right? That is a true statement. Okay let’s have the stitch.
Okay, come in closer please. Back up please. Okay you can just let that hang on the blue thing there with your, and then you can get your right hand and then, cut please. I'll tell you when. So this is a, you see this? This is an endo loop basically, so it’s a half hitch, 8 times around, 6 times around 2, so this is a the same as I'm going to make my own handle it basically it's a half hitch 8 times around 6 times round 2 3 4 5 6 okay now spread the two things, snap to me please. Put a half hitch along the bottom. Everything going the same direction. So essentially it’s a granny six throes on the bottom everything going the same direction. So essentially it’s a granny with 6 throes between. Okay now grab the tail of this please. So that’s like a hangman's noose let go.
Okay now expose a hiatus for me. Come in closer. Crystal take the light back for a sec. Okay so that’s just like the endoloop? Well it’s like an intracorporeal loop but it’s not square yet. it's going to slip unless I put some square knots on top of it. But if it's enough friction to hold that. Okay, scissors please to me. So that I can back up on the camera. Empty needle holder please. Come closer please. Scissors please. Come closer. Okay, stitching.
Now we’re getting really close to the cavae. That’s the problem with this right sided relaxing incision right here, you’re going to be right on the cavae. So the cavae is right there? No that’s the edge of the cavae right there, so we’re 1 cm away from it right now. I thought it’s that white thing right there. This is it right here. Yea that’s what I mean. And it’s right here. Yea, okay. When you pointed I thought you were pointing. Pointing a little bit more inferiorly. Okay that’s interesting. Fascinating. It’s just interesting how it likes sneaks up right next to the hiatus. Yea, right, absolutely. You always think of it as behind the body but it kind of comes in front of the-Well the carotid is wrapped around it, it’s sort of like a saddle around the horse in terms of the cavae. It’s just amazing how close to the top of the that cruss. Yea. And there’s a printed vein that drains into the cavae right there. Yea well you can see it right there. And when you take of that.
She has got a huge phrenic vein. I know and when you tear that it’s a whole lot of hurt. I find a lot of PHs have a huge phrenic vein. That’s right. I don’t know why. I noticed the same thing. It’s just a world of hurt. Now that’s starting to look respectable. Now if that’ll hold and not tear we’re good. One more stitch please. I think that’ll do it. Just a little bit tighter. What we can try to do is get that to that but I don’t think that’s going to hold very well. Yea it’ll probably rip right? Because there’s no muscle up there. See the pericardium is right there. Right.
It's just better to close I think posterior I don't like the interior stitches. I'm going to get good light so you can see this. It’s actually can important step. Cut please. Okay snap please. Okay this will be the last step in mine and then we're going to switch to silks okay? Okay? Okay that should be fine. You want the silks to five and a half? Yes, please one six inch the rest five-and-a-half so the the other thing that's important here is notice how much esophageal length stopped joint we have now compared to when we started right because we really transpose the hiatus. Yea, when we started a cruel closure. Looks good. It looks quite good. Pleased. White grasper, please. Relax for just a minute. Let’s just get things back in normal position, okay. Let's just see it for a minute. Yea just let go of the grasper for a minute.
Let's get just a panoramic shot here so we got a nice picture here of the length of the esophagus I can see we've got all this length right there and we didn't have before, okay. So it’s like two, two and half. It’s not perfect but it’s good enough. The vagus is good enough here. Where would you say the GE junction is? I would say the GE junction is probably right here because that's the front of the esophageal ligament. So the hernia sac attaches right at the front of the esophageal ligament. So the where’s the ligament? The ligament is where we cut, right there. The hernia sac is anchored in front then goes encephalitis into the chest. Right, this is all hernia shift. And that’s lipoma you were talking about. Right, that’s the lipoma, it’s painful to deal with. So you have to see if you can wrap-I think I can do a posterior funnel plate, I think I could do a standard tupe and gastropex it should be fine.
So that goes to there. So if we were to take something like this and pull that around. Okay why don’t you take the blue thing again and pull that straight down. Go closer whenever you have trouble. Okay that’s good there. Pull back. Now let’s make sure we’re orientated. That’s a good sign because that’s a short gastric, which is what we want. We should have a line of short gastrics. You know you’re not twisted. Pull down straight down like that and we’ll see what happens here. Usually that’s for a remnant of the sac in vagus and Bellsy’s left. Okay so I think this goes like this. Let’s like at this left side a little bit more closely they're short gastric. Short gastric there, so you want to see the short gastrics lined up right across the top of this fundoplication. Pull over again, down over. Twist a little bit I think not crazy about that. Let's try this again. That’s the piece we really want. So we want this to be like this. Lift that up and over. Let’s look underneath here. That’s the piece I want right there. Okay pull straight down towards the feet again. Okay that’s what I want right there. Try a heavy 4 I guess.
Let’s look at the left side for a just a second, let me do this shoe shine test. Now it’s straight, see? That’s straight. Okay. Stitch please and silk stitch please and a dolphin. This is anterior vagus right there that needs to move this way. That’s a full thickness? Not full thickness. Look down here for a second. Is this a full thickness? No, I want a good robust bite, I want to make sure I don’t just get hernia sac, that’s why you trim it off. So that is the full thickness? You don’t want it to be full thickness. You want it to be seromuscular to be honest with you.
Come back up to the hiatus please. Okay, why don’t you let go of what you’re holding for a minute there. Get a blank grasper please. This is 5 ½ inches. Just stitch, really, okay. Just hold this, somewhere in there is fine. Come in closer with the camera please. Just a little closer with the camera. Come in closer please. Closer still. That’s good, like that. Okay a little closer, please. That’s not very good. Give me an angle. Just try not to do anything bad to the caver or something like that. Cross this and this would be poor form. Okay, scissors please. Swing the stomach over towards the right. Good. Okay, so...after we get into the liver. After this I need 1, 2, 3 more. All five and a half. All five and a half, okay.
Puncturing the posterior descending artery never hurt anybody. A little puncture of the posterior descending artery with needle never hurt anybody, right? I mean you have a heart. It’s like Sergei’s talked about that minimally invasive mitral valve. Stop. It’s really quite impressive. It is actually. If I had something really wrong with me I'd rather have heart surgery than have some sort of PCI, more definitive. Yeah I mean especially for multi vessel disease. and it's increasingly, quote, “debated“ but I think the literature is actually-Alright so this part’s done, what we got is, about 3 cm of esophagus in the abdomen, petical of sac that has the vagus nerve running over the middle of the esophagus a two pay fundoplication, gastropexy twice posteriorly, twice anteriorly and that should work. Alright now let's take the liver retractor off and let's figure out how we're going to do this.
Give me a blunt grasper please. Stay right on the capsule of this I think, I assume it's a benign lesion grasper please. Let’s see, where is the deep part, the deepest part of this. Okay so if I go like this you can start coming across from my grasper there. And you can grab the white stuff there. I’ll rotate that up for you. Hold on a sec, Steve. If I flip that up you should be able to grab it. Okay that’s good there. You can take the other side out. Slow speed. Keep going one more. Good, I think almost could come at it from this angle over here. So it rotates, yea, see it’ll flip like this. YOu can come right along the edge of that. Well hold on it for a second. I think it’ll just come out. No it’s not gonna come out. I just wanna put a stitch in. So before we do anything else we’re gonna leave this here for just one second, okay. Right underneath here. Let's have the zero vicryl please.
Here put your first one in just like this. Don't angle too too much. Something about like that. Make sure you’re in the actual hole and work on a skin incision. There that’s perfect. Pull back. Stay still! Got it. Same thing on the other side, same of what you just did, exactly the same, except you’re going on the other side of the trocar. Put the end of the stitch back in and suture pass. Good, now we’re gonna move like that and you’re gonna go in just about the same hole you just went in. Okay, good. Alright, that’s that. Now let's have the endocatch bag. Let’s put the endocatch bag there. I'm going to take it a grasper of some sort, anything, just any grasper. Open it up. Let's go to someplace you can actually get that to fall down to the bottom of the grasper. Yeah, good okay close it up. That looks really good there. Turn the room lights on please. That's fine take that out.
So I think that case went very smoothly we’re able to reduce the hernia without too much trouble identify the vagi, do a nice solid repair of the crura. We’ll see whether her dysphagia improves and we’ve removed and incidentally discovered liver mass as well, so added bonus. Nothing out of the ordinary there hopefully the gastropexy augments the effect of the coral closure and her swollen will get better.
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