Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy

CHAPTER 1

I am Charu Paranjape. I'm the Chief of General Surgery and Acute Care Surgery here at Mass General, Brigham's Newton-Wellesley Hospital. I'm also a surgeon at Mass General. I do robotic and laparoscopic minimal invasive surgery as my elective focus. Today, we're gonna do a case of a paraesophageal hernia. This patient has had both pressure symptoms, as well as reflux symptoms from a large paraesophageal hernia. So we are gonna be doing a hernia repair, possible mesh, a fundoplication, and then an endoscopy. So the key steps of the procedure are, number one, proper exposure. Number two, we have to go and dissect the entire sac that's up in the chest. So part of his stomach has herniated into the chest. So we have to dissect the entire sac in the chest, completely close the sac, and bring it down into the abdomen. Then at that point, we are able to sort of define the right crus and the left crus. And normally, as we know, there's no big opening between the right and left crus. But in these cases, obviously there's a big hole through which the stomach has gone up. So after we reduce the sac, we close the defect, then we do a fundoplication. In this case, we're gonna do a 360-degree fundoplication around the esophagus. And then, the last part is doing endoscopy to make sure everything looks good. Robotically, there are certain key advantages in foregut surgery, particularly if the patients are obese. Number two, if the hernia sacs are really big, it gives you a better perspective, better visualization, and different angles that laparoscopically can be a little bit difficult. The visualization of the field and the field of dissection is superior robotically. Robotically, we have wristed instruments. And so, we could go all the way up in the chest through smaller spaces and do certain maneuvers with the wrist movement that we are typically don't have laparoscopically. One of the key advantages that I find in these cases in if the patient has central obesity or significant obesity, which in this case, the patient has intra-abdominal significant fat, the robotic vision, as well as the instrumentation, gives another sort of added advantage. And lastly, but not the least, robotically, I think we can close the crura much more stronger because we can take deep bites after defining everything, so that it's a much stronger repair robotically than sometimes laparoscopically. When we are doing with Endo Stitch, we sometimes do a partial bite of the crura. And that might be responsible for a slightly weaker repair.

CHAPTER 2

So like I said, one of the key things is I always look at this. Yeah. If it is like more than sort of 15, the advantage of the robot is that the robot has long arms, so that's a... You can still go here if I want to. But laparoscopically, it becomes difficult. So you have to go up. So typically, you would go... I mean, it's close to 15 here. So we could just make it go here. And typically, you want one finger breadth here. And then, we are gonna... Maybe you want to like cheat this way a little bit, so like that. And then, here, typically you divide this distance and go a little bit like this way. Is it okay like here somewhere? And then, this will be our five for the liver retractor. All right? Take the knife. All right, here. I'll take two S retractors and couple of Schnidts, please, thank you. Incision. Incision. 79%. Thank you. Great. Knife down. Take that. We can go down to the fascia. so here's the fascia. Clean that, he'll take the knife. Just incise the fascia right there, great. And then, I just typically just advance this. He'll give you the blade. Can I have that? I'm just releasing tension here. Yeah, there's one more layer. I'll take another Schnidt, either a Metz or... Yeah, a Metz will be great. And another Schnidt or... Great, and I'll take the trocar, gas on. Can I have a reverse T-215, please? So I always like direct open Hassan technique to get in. Everybody has a difference preference, but... Do you need it slid towards the feet to get lower, or do you... Yeah, that would be great, if you want to do the lateral first. Yeah, maybe even more. Go ahead, you can do it. But we don't have complete pneumo yet. And then, do this one as well. So maybe cheat a little bit higher, and yeah. Okay, so now when you go in, you have to direct towards the... Once you're in, so once the peritoneum is sort of indented, then you want to direct it towards the left shoulder of the patient. So as you come in, and now... Correct, so now I would change the direction, correct, towards, correct. Excellent, just til that black line, yeah. And this one, same thing, yeah. Yeah, so straight down first. And then, once it starts... Yeah, now change the direction. So keep that tension on, and then correct. I'm gonna give you this. You gonna put it in the lateral port. Look at this here. Okay. And then, look over here. Is this good for you, right here? Yeah? All right, liver retractor. So, since we're waiting, there are different ways to approach the hiatus. The two main things that I'd like to mention now. So one is I like to do the right side first, right side of the patient. Yeah. So I'm a right side first guy. So I would open up the hepatogastric ligament first. Okay. Identify the right crus. And then, go along the right crus all the way to the apex, and then down the left crus, and then come back to the junction of the right left crus. Yeah. Some people do it the other way. Dissect the right towards you, and then... Yeah, I do the right first. Yeah. Yeah. Some people do the other way. They do the short gastrics first. They identify the left crus, and then go up, and then they'll go down the right. It doesn't matter, you know, it's ultimately the same dissection. So that's number one. Number two, one of the best analogies that I have heard, and that I followed that all along. And so, in my fellowship I heard that analogy, was that this big paraesophageal, which this one is, so imagine them like a big umbrella that's open in the chest. Yeah. Okay? And so, the umbrella will have spokes, you know, inside the umbrella so that things will be going in. And if you go and just concentrate on the spokes, you will be in a different and a wrong plane. So the idea is to be outside the umbrella, go inside the chest, close the umbrella completely, and bring it down. Yeah. Okay, so essentially, the similar concept to the TAPP repair that we're gonna do next actually is that the sac completely towards us. And as long as the sack is completely dissected, you know, you may or may not excise the sac. The sac is not the strength of any hernia repair. Yeah, you want the mesh underneath that. Yeah, so the repair has to be completely on the other side, right? So in this case, that's the principle. So I'll show you here. When you identify the right crus, there is a very fine plane, which again, robotically you can see much better, that is between the crus and the sac. So you wanna be in that plane to all the way inside, almost like the breast stroke of swimming. Go like this, completely do like that, and then come, you know... And sometimes in very big paraesophageals, you have to do that in pieces. So in other words, you do the right side, then you go on the left side, do that side, then you connect the two together. Then go posterior behind the esophagus, identify the aorta, clean up everything over there, and then bring it down, so... We did an inguinal hernia robotically. And I can kinda imagine... We were focusing... We were like inside the umbrella, if that makes sense, and basically just cut through the sac. Exactly. Yeah. Exactly. So you will... Find the plane. Correct. Yeah. And that's where I think this teaching point that you will see, it's so important that if you are inside, then like you said, you know, you typically are like lost. And then, you're trying several minutes to just find where things are. So instead of that, you wanna be... Right from the outset, you wanna be like outside the umbrella. Yeah, yeah. Technical difference, paraesophageal versus sliding hiatus, so there are four types of hiatal hernias. There's type one, which is sliding. Type two, so the difference in type one and type two is where the GE junction is. So typically, in a pure type one, the G junction is above the diaphragm. Okay? - [Male] Yeah. Type two, the GE junction is below the diaphragm, but the part of the stomach is above the diaphragm. So GE junction is below, but the rest of the stomach is like this. You'll probably see in this, and which is the majority of the cases, many times, is this type three, where both... It's a combination of one plus two, right? So significant amount of stomach is up in the chest, and as well as is the GE junction. And then type four, you think about kind of like a type three, but it has additional abdominal contents. So you, you might have colon. You might have liver, pancreas. So see how it goes above it. So you want your instrument to come in, grab it, and then push it under. Correct, it snaps, yeah. Yeah, perfect. Good, that's what we needed. All right, good. It's very big, huh? Yeah, the retractor? Yeah. Okay. So Tom, we are lifting the left lobe of the liver up with this retractor underneath. It's not good. Drag the laser line to the endoscope port.

CHAPTER 3

All right, so there's a lot of big chunks of omentum here.

CHAPTER 4

So I open the hepatogastric, then enter the lesser sac from this side. And one of the teaching is that you want to identify the right crus. So there is the right crus. Once you identify the right crus... So I can cut it here, right? But no, that will be not the right or ideal plane. You wanna be here. And what I mean by that is you want to stay right on the crus, so... Is that retractor... Can it be like that? Yeah, I'll hold it. Okay. So again, I'm trying to identify where the crus is, and trying to stay... Again, if you can tilt that just a little bit to... Yeah. So one of the teaching, another teaching, is stay on the crus, not on the goose. So here is the plane. I don't know if you're seeing this. Yep. Which I am actually outside the hernia sac, but getting inside the mediastinum without cutting... That's the other thing is without cutting into the muscle. So this muscle is our strength. That's what we are gonna repair. And so, you should not cut that. There have been studies to show that when muscle is cut, there are higher chances of recurrence, obviously, because of that fact. So I'm not even bothered by that stomach that's going inside, right? I'm staying outside the sac, if you can see. Is it possible for you to just depress this a little bit?

CHAPTER 5

So here is the right crus, right? I'm gonna take this just a tiny bit, little bit here. So I'm gonna use this right there. See that sac sort of? Yeah, the hernia... Yeah, correct. So here's the plane. And typically... Typically, there will be a lipoma that's associated with the bigger sacs like this. Do you want a patty? Yeah, and also, do you have a suction? Yeah. Sure. Right in the way, sorry. No problem. Retract again? That's good. No, I think we're okay, but I'm gonna go on the other side. So here is lot of stomach going up in the chest there. Yeah, if you can grab... Yeah, thank you. So going back, here's where we stop, right? So I'm gonna go and sort of go towards the apex first, making sure I'm outside the sac. And as I do that, I will start seeing the left crus, 'cause the left crus is around there, right there. So as I see that, I'm gonna start going down again with the same same principle that I want to preserve the left crus, not cut the left crus, yet separate this from the left crus, so I can go in between. Thank you. It will make sense once you start seeing the plane. So here's the sac, as you can see. See that? Yep. And here's the lipoma. See that a lot, a little bit. In the sac, you mean? Yeah, usually they are this prominent. So one of the reasons you mentioned you don't see the type twos anymore is because I think people have lost the art of doing upper GIs. So very few places do a good upper GI, you know? And so, you never see that anatomy. You can depress that. Yeah, thank you. You can hold that, thank you. This one thing that I just did, I learned a little bit later. A lot of clutching, you should do a lot of clutching, so that your hands are comfortable. Otherwise, your shoulders start hurting. So again, back to basics, right? This is the left crus. So you want to keep defining the left crus without cutting it. Let me see where my other hand is. Here it is. You think a little more reverse T would help? Yeah, sure. Can I have like 18-degrees reverse T? Yeah. Thank you. Ready for table motion. So that's where the crus is, this is all - these are all the short gastrics. So you can - technically, you have to take all this down, so we can start somewhere here. So you see me opening the lesser sac here. I'm gonna advance my left hand a little bit, like that. So these are the short gastrics. So we're getting into that same plane. This was the sort of the paraesophageal part of that hiatal hernia, where you would see the stomach was sort of twisted there. I don't know if Catherine, you can depress this stomach a little bit like this. All right, let's come out. Yeah, it's there, right here. So now, we will go a little bit on the other side to sort of connect the dots like I was telling Andre, that sometimes you have to do here, then there, then back here. Need the suction. So see this lipoma? So the teaching is that you reduce this lipoma and everything will come with you. And whenever you want to cut anything, make sure you're on the crus. So here is sort of the extension of this lipoma. As you start doing that, you will see that you're getting on the other side. So now, I have to define the left crus completely, and make sure there's nothing going this way, right? Suction, yeah. I'm just gonna elevate this a little bit. So here is the left crus. This is the left crus. So esophagus. That's the vagus here. I will take a patty, actually. You can take this one and gimme a fresh one. All right, if you can come in and depress this fat right here. Yeah, thank you. Okay. So you can start making some sense now, right? This is the left crus, right crus. We still have to completely immobilize - that's the esophagus, but we are close on this side. And we'll do it a little bit on the other side. Then we'll measure. We'll see where the GE junction is. We'll also see the vagi clearly. So we are gonna go on the other side a little bit. Yep, nice, thank you. Want me to grab that... Yes. Yep, so see this guy, we need to just make sure that's completely reduced. Again, so I'm just trying to define... He's got a lot of fat. This is sort of the last piece of that sac. And I'm cutting it right on the crus. Yeah, a little suction. Okay, and we're gonna go on the other side again. All right, so may I have some suction? So there are two type of obesity. This guy has the intra-abdominal obesity. So you can see how much just omentum and everything is just full of it, everywhere. I think we need to clean this a little bit here. Then we will see the vagus nerves. And then, we'll start closing the hiatal hernia. All right, that looks pretty decent. This looks pretty good. All right, so this is... The aorta is gonna be right there. In fact, that's the part that's coming down, as you can see. That's the aorta right there. So the vagus usually right there, see that? That's posterior vagus, everybody, right there. Is Andre here? Yeah. So it's posterior vagus right there. And... Here is the anterior vagus, right there. Right there, see that? Right here, so this is the anterior vagus, okay? So we have both vagus intact. I would love to have a like a clearer... So maybe suction, irrigation, irrigation, suction combination. Yeah, why don't you irrigate just a tiny bit. And then, yeah. Oh, I see. All right. Good. So if you want to depress that and give me the suture... You can use the... I can use the needle driver. Oh, it's a 0 V-Loc, so…

CHAPTER 6

So the, Andre, the other thing is one, two... So the GE junction is here, and like two and a half, right? So we've got two and a half lengths of this. This is about 3 cm. So we got enough esophagus. Yeah. So I love the fact that with this, we can take a full good bite of that crus. You know, laparoscopically, typically, especially with Endo Close and Endo Stitch, you end up taking partial bites. And it's not obviously studied, but I think that probably leads to a lot higher recurrences. So when I close this, one of the thing is... One of my advice would be not to pull on the crus so much, but to push the crus away as you tighten up this. So when you tighten this, try not to pull the crus, but rather push it away. So open the jaws a little bit, and then sort of push this away. See that? That way I'm not actually pulling it out of the body. I will probably take another one, so I'm gonna try to lock it. So I like the horizontal mattress. I think they are stronger than simple. And I tried to get the knot on the right crus because, again, I think the right crus is straighter and has more strength than the left because just from the anatomy. Slightly tricky to suture without the needle holder on the left. See how I'm rotating a lot, rather than pulling? So just like open surgery, it's a lot of rotation, rather than... In laparoscopically, obviously, we have to... We don't have the wristed motion. And so, you tend to pull. All right, so maybe one more. You never want to do this too tight. If you haven't opened it, don't open it. All right, just us know if you need it. Yep. All right, Andre, you want to just go back. So I'm not gonna make it too tight. Maybe just, I'm gonna start with one. But then you can just come back. So I'm gonna go over. Okay. All right, so I want you to just go through and through, and then lock it. You can just do a forehand. Okay, you have it? Yep, it's not letting me... So swap left side. You just swap, push the swap button. There you go. So I would get hold of this with your left hand. Pull it up, just like open surgery Pull it up, yep. And now, under that, completely, both sides. See how you're going halfway, right? Yeah, you want it all the way? Yeah, you want to be over there. Got it. Yes, good, perfect. So let go. And lock it, lock it. So go, yep, perfect. No, you don't want to do that. You don't want to tear the, yeah, perfect. Slow, nice and easy. And then, pull down. Like instead of pulling this just, like I was doing, right? So you want to, - yes. And do that a few times just until you think it's nice and tight. Don't dig in your, your left hand is... Oh, careful, man, careful, careful, careful, careful. All right, that's good, perfect. All right, she's gonna cut it. So watch your left hand, the IVC is right there. Yeah, I'm just gonna feel it. Just one sec, one sec. Yep, feels good. A little higher. All right, you can take this. You can take this guy. Needle out. All right.

CHAPTER 7

So now, you want to see how much of this fundus is mobile, right? So... If you go by how the French do it, measure 6 cm - one, two, and three, that's perfect. I'll take a stitch. Creating this loop, so it's easy to hold later. All right, she's just gonna cut this maybe closer. Needle back. Do we have a 54 Bougie? Yes. Okay. So, we're gonna put this hand over here. And then let this go. If you can hold this fat. Let me see my hand. Let's do it again, I'm not happy. Okay. Hold that, yep. Okay, so now I have to feed this guy to that guy. Okay. So I'm gonna hold this, all this thing down, yep. Here's our stomach on this side, right? So, this, this... Okay, you can let go.

And now, we do the shoeshine. So what happens is... Can we lift that liver retractor just a tiny bit? So this is all the rest of the sac, right? She's gonna hold it for a second. We wanna make sure you do the right fundoplication. And when I say that, you have to be careful, like which fundoplication, which part of the fundus you fundoplicate. So for example, I might be tempted just to do here. Yeah. You know? Because you can see... Right? But this will be the wrong thing to do. You know why? Because the real thing is underneath. So she's gonna actually hold this stomach. Can you hold this stomach? Sure. Yeah, it looks like that... And fold it over. That would be like a really loose wrap it looks like. No, no. It will be the wrong wrap. Not loose, wrong. You know why? Because the answer is here. Look at that. Yeah. This is the real fundus that you wanna wrap. Yeah. Right? And so, otherwise, you would've wrapped this guy, right? Yeah. Yes. And that's - I have seen many times that mistake. So, now that that is so, I'm gonna let go of this. And I'm gonna straighten this out. This is all the sac. I'm just gonna depress it like that, right? So like this. And see that? Yep. So this is the fund - This is the shoeshine. Yeah. And we will do it here. You can do it like a loose, you know, 360 versus partial. Did you see his manometry? I saw that it was grossly normal. Correct, so we can essentially do a complete, right? A wrap, yeah. So, before that, I'm gonna pass a Bougie down, right? So we're gonna keep - you are gonna take control now. And you're going to make sure that you have this. And I'm gonna let go of this guy because that's where the Bougie's gonna come. Can we flatten him? Flatten the bed? Yep. I'll take a 54 Bougie. All right. Check port position and check patient clearance. You have the control, so you're gonna keep your control. Ready for table motion. That's level, thank you. Thank you. All right, you should see it coming down. The omentum's kind of in the way. I can have the monitor up towards you? You can, yeah, there you go. Perfect, yeah. Okay. All right, great. All right, so now, we're gonna basically do our suturing. So she's gonna give me a stitch. Check patient clearance. And this, Andre, this doesn't have to be super tight when you suture this. So I'll put one, and you can do the second, and then the third one, depending if you need a third one. You typically also do a pexy posteriorly, so we can... Thank you. So this, what she does is a very critical part where the sac is completely used as a buffer. Yeah. So the sac is down. So here, just like we would do in a TAPP, I use the sac as a buffer in between, but I don't have to excise the sac necessarily. And let go. I'm gonna leave this down. So typically, and I know you know this suturing, but typically, the opposite side of the tail is that's where you would use your arm to go around and go like this. And then, you know... So now, the tail is on that side. So I will actually do the other way. So it's this ways, so I'm gonna use it here, go around this way, and then that it's gonna be right there. Scissors. Are you out? Thank you. How many more would you like? One more. All right, if you can hold this down for him. Just this, yeah. This is all sac, yeah, perfect. All right, you have the control? So yeah, I would go like here, if you can get this. Yeah, perfect. Yeah, perfect, right there, big... So grab the stomach if you want to and make sure you use clutch. Yeah. And zoom in if you want. But don't bring the target towards you. You move towards the target. So you're right now grabbing something else in your jaws. Correct. Yes. Good. Rotation rather than pulling, correct. A lot of rotation, correct. Reload. And then, I would just go under this and, you know, there's a little serosal thing here. See this, right here? Which? Oh, yeah. Yeah. So I would just move your... You don't have to grab that. You actually, you grab this fat and push it down, so you can see it. And just go under that whole serosal tear. Yeah. Yeah, towards here. Towards there, correct. Yep. perfect. Yeah, keep rotating, it will come out. Adjust your camera. There you go. Rotation rather than pulling. Yep. Just imagine this is open surgery, you know. Just your motion should be just like your open surgery motions. Just tie three, four knots. Four, at least four, if not more. Okay. So, correct. Flip this guy, yeah, this one. This, yeah. That way, correct, yep. Okay. Like I said, it doesn't have to be super tight. Just take this. So now I would give a bigger loop for myself. So zoom out just a tiny bit. There you go. Hold it long, you... Yeah, correct. Yeah, now when you do that, it will be right there. Correct, right there. Okay, tight, tight, tight. Nice, that's good. Two more. Nice, yep. Yep. One more. Nice, okay. I would cut both, so hold both up. Yep, there you go. All right. Needle back. Give it to her. I'm gonna take it for a second. All right, I'll take one more. One more? Yep. So I'm just gonna do a pexy in the back. This is not needed, but it's just another... So you can do it on the left or the right, doesn't matter. You can do it here, so... Sorry? Do you want me to hold something? No, I think we're good. Okay, you can cut this. Perfect, needle back. You can take my needle holder after that. Will you flatten him, please? Needle out. And I'll be ready for the EGD. I'm gonna give you the control. So just toggle once, peddle, so you have a control over the other. Then it will be ready for table motion. Can we put some of that 20, 30 cc of our solution at the GE junction? Yeah. Thank you.

CHAPTER 8

Our suction is a little weak. I'm in the mid esophagus, just FYI. Still weak. All right, I'm in the lower esophagus. This is the GE junction. My pet peeve is when you - now I'm in the wrap - so it should go straight into the stomach. If you have trouble finding the stomach, that means the wrap is not correct. So here is the stomach. So now I'm retro flushing. So if you look at the preoperative images, you'll see that there's like a big giant hole there. Now, it's being replaced by this wrap that we're gonna look at it. So around the scope, you're gonna see this wrap, which is the fundoplication. So this looks good. I'm gonna un-retro flex. I'm gonna do this one more time just to see the angle of how it enters the stomach, 'cause that's where the dysphagia sort of happens, if there is any. Is it completely desufflated? It looks like. Got a little bit. Maybe up top, okay. We can un-dock, coming back. I'll suction the back of it. Great, thank you.

CHAPTER 9

So Tom, if you haven't seen this, this is called Endo Close. So instead of closing it from outside, there's a technique where we can close it from inside. Can you turn the flow to high, please, Maricelle? Yeah. Yeah. Can I have a grasper? Yeah, he will take a grasper. So, this has holes, this cone. And so, we're gonna go on each either side of this. There you go. Okay, so that's one side. And this is the other side. It's a nice technology here, so you don't have to, especially in larger individuals. And you can do this. Just go wrap it around and I'll get it. Wrap it, yeah. One and, yep, there you go. Now, when you do it, just come up between the two. Between the two, yes, perfect, yep. Awesome. Great. I'll take local on a needle, please. I'm okay with Toradol. So the diet in this guy's post-op day 0, it's clear. So with 5 no's actually: carbonated beverages, caffeine, chewing gum, straws, and Jello.

The first thing they give when you write clear liquids is Jello. And that Jello has no weight, and it sort of sits at the GE junction. It's very irritating for those patients. So chewing gum, straws, and Jello. The straws and chewing gum cause aerophagia. And so, you don't want in the stomach to be... Distended? Correct. PPS, we take it off when we see him in the office. Okay, and he's okay for pills, medication? Yep, everything he can take, a lot of walking. They get a scheduled dose of MiraLax today, and then a scheduled dose tomorrow morning. Now, he wants to really go home. Tomorrow, yeah. No, tonight. Tonight, okay. We'll see. We'll see. I told him that we will see. But at home, he continues the MiraLax until he starts going, yeah. All right, we're gonna switch roles. You're gonna take the local. So I would do like here, yeah. Oh, which one, this one? Yeah. Okay. So that's preperitoneal. You wanna come back just a tiny bit. So you have to see the transversalis getting bumped. Yeah. Is that better? I can't tell, lemme... So I think you might be too superficial. Thank you. So choose another point. Choose this point, let's say, or this point. Yeah, choose that right there, right? So actually intentionally come into the preperitoneal space there, so move this just a little bit that way. Yeah. That's me right there. So, yes. Not really. Here, I'll show you one. I don't want to do it, but let's say this is a point. You can see that that is the transversalis right here, right? Yeah. So, you want intentionally to... I'm gonna come in, and you go ahead and inject right there. Go ahead, so that's gonna be preperitoneal almost, right? So you can see that. Now, I'm gonna come back. Yeah, there, right there. And, you want to see that bump. So actually, you're pushing my finger. I don't want to push it. So if you go like this, it will be there. You're gonna come back right there. See that bump? Yeah. In ultrasound, you see the same bump, all of it, right there. Yeah. Okay, one more here. Okay, perfect. So get half there, and then we will use half here. So 190 of the mixture, which is 85 of the... Or 95 of the... Yep, perfect. Great. Half there, and then we'll use half directly at the fascia. All right, you can take those ports out. Those ones you can leave... Yeah, put the needle in here, yeah. Show me here. Perfect, all right, you can take that. Just take the scope out. Yeah, hit pneumo out, right? So I want to just take the scope out. I see. Stitch to him, hemostat to me. Actually, before that, inject the local here. 22. All right. Thank you. So, a needle holder. So you just reload the needle, and just go under the whole thing one more time and just tie it, yeah. Perfect, thank you. So just one at the center of all these. This you may require two interrupted. The other ones just - one just in the center of subcuticular. And the Steri-Strips do the rest. Debrief, yeah. So robotic paraesophageal hiatal hernia repair without mesh, fundoplication, and EGD. EBL minimal, no specimen. All 190 of the local, and no concerns. Thank you. Thank you.

CHAPTER 10

So there are several aspects of this case, which are slightly different than the normal cases. Number one, as we saw in this case, the left lobe of the liver was slightly bigger than the average. And so, we had to use a slightly bigger liver retractor to retract the liver up, so that we could expose the hiatus nicely. And so, this we find in different patients that we have to sometimes adjust, depending on the size of the liver. Secondly, in this case, we found that the patient had significant amount of intra-abdominal fat. And so, we had to sort of either push that fat away or retract that. Having an assist port helps. And so, in this case we had one assist port, where the assistant was able to sort of retract with an additional instrument that extra layer of omentum, or distended stomach, that we could retract. So that was another key difference. Other than that, the patient did have a significantly large paraesophageal. And so, dissecting the entire sac, identify the vagi nerve are important. And we were able to do that without a problem.