Robotic Paraesophageal Hernia Repair with Magnetic Sphincter Augmentation Using the LINX Device

CHAPTER 1

Hi, my name's Jonathan Levy. I'm a surgeon at University of Michigan Health-Sparrow Hospital in Lansing, Michigan. Today I'm going to be performing a robotic-assisted laparoscopic paraesophageal hernia repair with magnetic sphincter augmentation, also known as a LINX device placement. So the indications for this procedure, this patient had recurrent and refractory GERD, so gastroesophageal reflux disease that was not treated on multiple medications that he had tried in the past. So his symptoms were heartburn, reflux, throat burning, and dry cough that was persistent regardless of how many medications or the type of antacids and anti-reflux medications he took. We performed an esophagram and an EGD that showed he had a hiatal hernia. It was about a five-centimeter hiatal hernia, and the decision was made to perform a hiatal hernia repair. The options were presented to him as either a fundoplication, so a wrap, a complete wrap, or a magnetic sphincter augmentation, and he chose to undergo the magnetic sphincter augmentation. So the steps of the procedure are first, port placement. We like to place the port. I like to do a varus entry, just lateral to Palmer's point, and I place that so we have more room to work across the abdomen, gain insulation with a Veress needle, obtain pneumoperitoneum, and then place the four eight-millimeter ports across the abdomen, making sure we stay far enough away from the hiatus that we are able to operate and work. From there, we dock the robot and we start by taking down the gastrohepatic ligament working up through the pars flaccida. We take down the pars flaccida of the right crura, and work our way circumferentially, anteriorly and posteriorly until we have the dissection plane. We're looking for an avascular plane going up into the mediastinum. During that time, after we have a full circumferential dissection, we place a Penrose drain to aid in dissection, and then we do a full mediastinal dissection as high as the level of the inferior pulmonary vein at least. I do try to go a little bit higher if I can. The goal is to find three to four centimeters of intraesophageal length, and at that point the hiatal hernia has been reduced. From there you look at the crura, which is wider than it should be, because that's what needs to happen in order to get the hiatal hernia. And we close that, usually with posterior sutures, and using posterior permanent sutures to close the hiatus. Once we do that, we will then place the LINX device. We have the LINX device here, it's shaped like this so it's easy to get through the laparoscopic port so we can stay minimally invasive. It goes through the port, there's a clasp on each side, and these strings help the instruments that are otherwise magnetic, manipulate this without the magnet getting in the way. We create a retrovagal window, so there's a window between the vagus and the esophagus that this LINX will pass through. It helps kind of keep it in place. So this clasp clasps in place like this, and it is a permanent clasp so that it stays like this, goes around the esophagus like this. We don't want it too loose, we don't want it too tight. We want it to be sort of the appropriate size around the hiatus, and sometimes that takes a little bit of, you know, figuring out over time. But we want, the idea is when the patient swallows, the beads open and separate, and then when they finish swallowing, the beads will then close because they are magnets. So this way it allows food to move through the esophagus into the stomach, and then prevent reflux from coming back up. When you see food go down or when you see in this video, the beads are going to separate one to two beads at a time, which is all you need, but it allows for larger bites, if there are any. All this is doing is augmenting the natural lower esophageal sphincter that has been distorted over time via the hiatal hernia and distortion in anatomy.

CHAPTER 2

So we're just gonna go lateral to Palmer's point so we can get all these in. So just, yep, that's gonna be an eight obviously. So by the way, incision at 33. Got it. Doing Veress needle entry. So gas insufflation in Palmer's point or just lateral to Palmer's point. We wanna feel two to three clicks till everything moves easily. We're gonna turn on the gas. Go in just a little bit more. Yep. There you go. Okay, you can go high flow. The best way to do that is hit the down arrow there and then hit 40. Perfect. Gonna get pneumoperitoneum with the gas. Yep, pressure's five. That's good. Now it's gonna insufflate, excellent. So then probably gonna be there, we're gonna go about six, so three of my fingers. Yeah, somewhere in there. Sounds like it's fine. Mm-hmm. All right. Okay. All right, so we're gonna place the first port. Can be done under direct visualization, but in this case he has not had surgery in the past, and we are gonna go in after insufflating, just with regular. All right, we'll double check. Take the camera, please. Yep, looks good. And when we place these ports, you're aiming somewhere between six and 10 centimeters between ports. You go sort of in between the xiphoid and the umbilicus. In general, you can't ever go too low with a robot, but we try to... We wanna make sure that everything is low enough that we'll be able to operate. So we double check, make sure there's no injury or anything. There's not a little bit of insufflation underneath the omentum, which we expected, but everything looks good. So we'll do... It'll probably be one there, one there. So we're gonna go about six centimeters in each direction, six centimeters away. And it's gonna be a little bit of a... It's either straight across or a little bit of a smile going across the abdomen. That's eight. Eight. And then take a look at the liver real quick, if you don't mind. So it's pretty high up there, so we'll be okay. All right. So it's a total of four eight ports, four eight-millimeter ports. Put them in under direct visualization. And for the robot, we wanna make sure that this black line is in the abdominal wall, which is the pivot point for the robot that just limits the amount of injury to the abdominal wall when it's pivoting. Okay, again, excellent. Thank you. Now we'll need the knife back one more time for the liver retractor. All right, so that's in, black line in the abdominal wall. All right, we will turn on the AirSeal. And that you can just get rid of, thank you. All right, in this case we use AirSeal, 'cause it gives a nice steady flow and we can do it at a lower pressure, which is really nice when we're dissecting in the thorax, and help prevent capnothoraces that are symptomatic. All right, I will take the knife again. All right, that's great. So now we're gonna put the liver retractor on. I'm aiming basically just to the left of the xiphoid process, and I wanna put it as high as possible. We will need to get the actual liver bar on as well. This is just to create an easier tract for the retractor to go in. I'm gonna set that down. There are many different types of retractors. This is the Nathanson liver retractor, and it works well in the sense that it's able to hold the liver out of the way, and helps open up the hiatus, which we're looking at right there. Nice, small liver which is great. Keep that kind of low profile, and that tightens in place in two ways and you can see the hiatal hernia right there. All right, may we do full reverse Trendelenburg please.

CHAPTER 3

All right, we can bring in the robot. So we're bringing the robot in, bringing it at an angle, and we want the crosshairs to be where the camera port is. So she's gonna be coming in. All right, and we're gonna rotate. Yep, perfect. You can raise it up a little bit more actually. Good. We wanna protect the liver retractor from hitting the arms. Okay, vessel sealer will go into three. Bipolar will go over here. All right, coming in. I'm watching myself come in. Vessel sealer in three. We're gonna put all these basically in the same letter if we can. So these are all an L this time. So we'll go ahead and put the cautery, we've burped everything. We have room in between each one of the ports. We're not on the liver retractor. I'm gonna put the pressure to eight, and let's see what happens. I'm swapping the camera down.

CHAPTER 4

All right. So we're looking up at the hiatus here. So we have liver above us, caudate lobe. We have the stomach going up into the hiatus here. This dimple here shows the hiatal hernia. So we have right crura, anterior, left crura right here. So we're gonna start by getting into the gastrohepatic ligament. So gastrohepatic, nice, safe area, and we're basically gonna work our way up. Caudate lobe is safe, so we know if we're around the caudate lobe we're safe. We take this down. Sometimes there can be a replaced hepatic artery. We do want to avoid that if we can. And I'm gonna just take this up and I basically wanna get to the crura, so I'm staying exterior to the crura as far as it goes in the abdomen. So I'm staying within the abdominal portion of the crura. I'm moving the camera as I go, making sure I get good visualization.

CHAPTER 5

Okay. So now I'm going to grab this fat here, and we're gonna basically get into the pars flaccida and open up the difference, the avascular plane between the right crura and the esophagus and stomach. You can do this with scissor. I like the vessel sealer, because I don't have to change instruments. I'm using the vessel sealer, extend here, which looks like a large instrument but works very well for our purposes. We're basically looking for an avascular plane. And that's gonna be the plane that separates the peritoneum of the crura with the rest of the hernia sac, which we're then going to try to reduce. So we found that avascular plane, and basically pushing, what is probably esophagus, out of the way. Gently. The goal here is to keep the peritoneum on the crura if possible. So it's a very tight plane you're trying to develop. We wanna be careful we don't hit either anterior or posterior vagus nerves in this area, and kind of coming posterior. So you can see the pillars of the crura coming in here. And sort of, in general, you're working basically around the clock face, and then sometimes I kind of just take what it gives me. So I'm gonna be working my way around, still a little bit of bleeding here. Just use the bipolar, don't injure the esophagus. You can see we're in that avascular plane in the thoracic cavity up here. So we're gonna be watching out over here to screen left or patient right is gonna be the right pleura. Underneath is going to be the aorta, this is the hiatus here, and above us is gonna be the pericardium as we march up. So I'm gonna re-grab with my right hand. We are using a single console robot. If we have a dual console, usually we have residents who do a good job of assisting. So a lot of this is done, you know, bluntly, without need for any energy. But there is a little bit of vessels in this area that are bleeding so we will take care of them. Here, I'm trying to make sure I do not hit anterior vagus nerve. So we're just sort of gently just kind of pushing everything down. So you see anterior crura's there. So my goal is to get sort of external to the crura, which is again trying to bleed at us a little bit, so I can be up here. So anterior vagus may be up in here. So I'm just gonna kind of push everything down. Always define that avascular plane again. We are just gonna work our way around the clock face. You can see left crura coming into play there. I do wanna try to keep the peritoneum on it if we can. We really wanna make sure we do not get vagus nerve caught up in this tissue as we take it. So maybe kind of coming down the left crural pillar. And just keep marching our way around. When we do this magnetic sphincter augmentation or LINX device, we do not end up taking the short gastric arteries, so we have to be very careful when we're working circumferentially. So here I'm just gonna, again, take what it gives me anteriorly, stay in this avascular plane, to take down the sac. That vessel there is gonna try to bleed at us, so we'll make it stop. That is not part of anything that we're concerned about, but I am gonna sacrifice it. You can see the esophagus coming into play here, and that is a part of the lung. You can see lung kind of coming into play. So we're just staying in this plane between the left pleura and the esophagus.

CHAPTER 6

And again, I'm kind of just... I'm taking what it gives me, marching a way around, just so we can see what's there. So you see the sac is densely adherent here on the left crura. And so I'm just sort of separating it bluntly, and see the sac is kind of right there, and as we come around, we'll end up taking it if we need to. This is the peritoneum here. Again, that's not part of the vagus. We can see anterior vagus coming down right there. So I'm gonna actually work my way inferiorly this way. Again, I'm separating inferiorly, so ultimately, I'm gonna connect the dots between the left and the right side. I'm just gonna make that... Aorta's gonna be down here. So we're actually gonna kind of find where the aorta is and clean that off. Sometimes there's some bleeding from the esophageal perforating vessels that feed the esophagus, but usually the bleeding is minimal if any. So I still try to do more blunt dissection than anything else, just to make sure I don't injure the vagus nerve. If there's any aberrant anatomy. You also have to sometimes worry about thoracic duct down in this location as well. Again, don't wanna work too much in a hole so I'm just gonna kind of keep coming and separating this, if we need to take anything we can. The trick is, and not to injure anything, but we can see that coming in, that's not anything. So we see posterior vagus is right here, anterior vagus has been protected, so we know that nothing is in here. The only thing that could be in there is pleura, but I believe we've pushed that away. Sometimes we do create an intentional capnothorax, especially on the right side, to help bring the diaphragm back together. However, we may not need to do that today. Sometimes we do just gentle pulling, sort of separate everything. You see the pleura is getting peeled back, or in the kind of just pushing and separating hernia sac and other tissue. The wristed movement of the robot is really nice here because I can kind of get in these tight spaces and run the camera up. Here, probably an esophageal perforator, so I'm gonna take this. I'm not putting too much tension on the aorta or the esophagus. Really wanna open this plane up. So now the aorta is coming into view. Kind of just gentle pushing and pulling to sort of separate. See another esophageal perforator. So we'll just go ahead and take that. We want to go high enough that we get three to four centimeters of length of the esophagus in the abdominal cavity. So three to four centimeters of intraesophageal length. That tends to mean we dissect at least as high as inferior pulmonary vein. Sometimes we dissect higher. In general, my practice is to dissect effectively as high as we can go, because I want to fully remove tension. I'm just gonna... And we still have a lot of work to do anteriorly, but posteriorly, we're doing really well. So I'm just gonna keep going. Again, we're doing this at a pneumoperitoneum of eight millimeters of mercury. Average pressure for a laparoscopic case is 15 millimeters of mercury. So we have a lot more working room without causing extra pressure in the intrathoracic cavity for anesthesia with ventilator breathing. All right, so I'm gonna gently, carefully come out here, see what a large cavity there can be. I'm gonna keep working my way around posteriorly, so now I'm external to the crura again. I'm back in the abdominal cavity fully, and my goal here is I wanna see stomach on this side. I may see spleen all the way through, and crura's gonna be here. So I'm just basically walking along the crura until I can finish completing the dissection that I had started earlier. See this black spot, nice open area, means that we're almost through, and then we'll be able to put the Penrose in. Again, we do not have to take the short gastrics. All right, so may we put the Penrose in, please? We'll come out of three, please. And then I will have to scrub back in, I think, to do the LINX sizing. Okay. Thank you. All right, so we have the Penrose here. It has been cut with a slit, so we can kind of create a little slip knot. And then do we have Ethibonds open? Yes. Sweet. Thank you. So a little slip knot around the esophagus so we can complete the dissection. One Penrose drain in. You said Penrose? Correct, one Penrose in. Thank you. And here again you see the crura. Pushing the crura away, and then this is just the last of the sac. Making sure we have vagus nerve protected, which it is up there. That's the vagus. We're protected here, so I can take this. You do in general wanna keep the peritoneum on the crura. In this case it is splitting a little bit, that's okay. We're just still separating the rest of the hernia sac. Sometimes it was all connected and you have to actually take it out. In this case it all came down very nicely, and I don't think the anatomy's distorted enough that we need to do anything with it, but sometimes we do have to split it. Okay, so we already have good intraesophageal length. GE junction is approximately right there. If these jaws are two centimeters, we have two, about four centimeters, which is really what we're looking for. However, again, I try to do as much mediastinum dissection as humanly possible. I really wanna do a full and complete mediastinal dissection. So I'm gonna continue working around the clock face, getting some of this. So some of this we had done earlier, some of it was kind of difficult to tell what it was, but now we have better visualization. Anterior vagus is usually coming up in this area, kind of at the one-o'clock to two-o'clock position, so you have to be careful. See the pericardium is above us, and ultimately, we're gonna get to the inferior pulmonary vein. Little bits of bleeding I usually leave alone, because again, I don't want to injure anything by taking a larger bite of tissue and coagulating it without knowing what it is. Here, I'm separating everything off. I know that's nothing. I see all this extra tissue here that is nothing. You can see it's not really attached to anything. We'll take that. And that gives good plane in which to continue dissection. This avascular plane is really what we're looking for, and it's what we were looking for this whole case. He had a larger paraesophageal hernia, it was about five centimeters, so the planes sometimes get a little bit distorted, which is what we saw. Again, I wanna make sure the pleura is out of the way here, which it is. And now I kind of go back to gentle sweeping because posterior vagus has some branches up here that I want to leave alone. We already did a lot of this posterior dissection. You can see vagus is right there. So I'm just gonna sort of hold that up as I sweep, make sure I don't cause traction injury or any other injury to either the pleura, the esophagus, or the vagus nerve. And the peeling that I'm doing is, in my mind, the safest way to do this. Another little esophageal perforator. I'm gonna come back. We're gonna continue working our way anteriorly and around. So again, we already established the anterior vagus earlier. I'll show it again, it is right there. Anterior vagus, we have it protected. Again, some people would've stopped the dissection by now. I do want to continue it as high as it'll give me, within reason. I don't want this to happen again. So we know anterior vagus is gonna be in there. I'm just gonna kind of sweep things down a little bit. So we see there, this is inferior pulmonary vein right there, coming across. It's actually not as high as you would think. It's always a scary place to be operating as a general surgeon, but you do it a few times and it's okay. I'm just gonna... Probably a little bit of nodal tissue that was bleeding there. We know the anterior vagus is down. We should be just about done here. With mediastinal dissection. Again, wristed instruments, very nice. The visualization of the robot is very nice to get high up in the mediastinum. Kind of peeling off of the inferior pulmonary vein, which, you know, be careful. Posterior vagus is right there, sort of peeling everything off. Again, a little lymph node. Okay. All right, so again, we have good intraesophageal length. If I release it, it does look good. Still a little bit more we need to do over here. Just really gonna be a big blow for freedom. Want to make sure we don't injure anything here. All this should be... This is just all sac. So we have crura there, we have sac. We're just going to... Just looking all the way around, seeing is there any more we can do? I think that's pretty good. Okay, so we will take the Ethibonds, please. Thank you. I'll cut to six. Yeah. Thank you. Let's do four for now. Okay, I shouldn't need it, 'cause we're doing the LINX, hopefully. And so just loosely, we're two or three centimeters easily. Thank you. Got it. Thank you. I'll take the Megacut. Thank you.

CHAPTER 7

All right, so these are Ethibond sutures. So braided, permanent suture. Many different ways to do this, but the idea is just to reapproximate the hiatus. I do it with simple sutures. So a large bite of the crura. Make sure you don't hit the aorta, try not to grab the tip of the needle, and then large bite on the right crura. Again, making sure you don't hit the IVC which runs a little bit more laterally here. I throw a square knot, that ends up being a slip knot. So the first one, first throw, I go one direction, then I go the other direction, and I bring both hands to the knot. I want this to be a short tail. So I pull it, and then I can grab it here and cinch it down. And it creates a slip knot. And I just complete the knot tying. You can tie with either hand. I've found it works very well to tie like this. Somewhere between four and six knots. You only really need four for braided suture, but a couple... For safety. We want to close the hiatus until it is relatively tight. Still wanna be able to get a grasper through there, but you want it to be pretty tight around the esophagus so that it doesn't happen - doesn't reoccur. Here I'm not getting the phrenic vein there. One of the phrenic vessels. Around one way. Other way, both hands. Really show the slip knot technique here. So grab here and just slide down. If it doesn't hold, it's either under too much tension, or you can pull this tail a little bit tighter, so that holds a little bit better. The tail's over there, so I know where we are. Usually I do this only with posterior sutures. However, sometimes you need an anterior suture. Either because it looks like there's a little speed bump when you do your EGD and it has to kind of go over all the hiatus, or if you need to sort of reef up the anterior portion to get a better closure posteriorly. I'm getting the esophagus out of the way. I like to slide with this hand because the other one has a suture scissor in it, and I don't wanna cut the needle before it's too late, before I need it. So I found through trial and error it's better to use the other hand. You see it's getting a little bit tight around the esophagus. So you see now we have about four centimeters of intraesophageal length after closing the hiatus, but it's still to me looks a little bit loose. So I'm actually gonna put one more suture in. Again, all these are large bites in the crura, because the muscle is the only thing that has any strength layer in it at all. It's also why we try to keep the peritoneum on the crura for the same reason. And I really want to lay this down nicely. So I'm gonna move this out of the way. If I wanna make it a little bit tighter, I can raise it up. I wanna make it looser, I can bring it down. But that looks pretty good. You can always... I'll release it a little bit, just make sure I can still get a grasper up there. Yep, nice and easy. So... All right, so we have a nice, tight hiatus posteriorly. We've recreated all the pillars. When I release everything, we have very, very good intraesophageal length.

CHAPTER 8

So again, we have proved to ourselves... Anterior vagus is in here, posterior vagus is in there. And we're gonna end up creating a retroesophageal - a retrovagal window for the LINX device. So I can do that now. What this does is it will help anchor the LINX in place posteriorly. So that it doesn't migrate. So I'm assuming that's about where the GE junction is. That's where the LINX is gonna lay. However, we will scope and confirm. All right Brooke, is the scope set up? Yes, it is. Perfect. I'll get it moved over here. Thank you. I'm just gonna grab all the sutures so they don't migrate when I'm insufflating the abdomen or the stomach. Get ready with the scope. I'm gonna put the scope in, just 'cause you don't need to see me get it into the mouth. Figured he has a good jaw thrust here. All right, so we're in the esophagus. So here I'm looking for the hiatal closure. I wanna make sure there's no injury to the esophagus during the dissection so far. So the hiatal closure, you see how it's tight right there. So that should be the hiatus, and you can see the... As the scope is kind of going through, we can see on the screen that it's right at the hiatus, which is exactly what we expect to see. So hiatal closure is at 40, which is exactly what we want. So we'll come through the hiatus here, and we should be entering the stomach, now we're in the stomach. So I looked at the hiatus at 40. GE Junction, or the top of the gastric folds is right there. So again, I'm kind of showing myself right there, which is great. It's got what we think and it's about 43. So we have three centimeters, at least, of intraesophageal length, which is what we're looking for. I'm gonna put the LINX on top of that. So I'm gonna fully insufflate. So then I can do the retroflexion, make sure we're looking for a Hill 1, or American Foregut Society 1, AFS 1 valve. Two different criteria but we wanna be able to see the GE junction. We wanna make sure that there's no recurrent hiatal hernia, especially when insufflating. I wanna maximally insufflate. I'm going to do a couple of provocative maneuvers to show that everything is opening. So you can see on the operative screen, everything is staying below the diaphragm, and as we're insufflating, you can see that there is effectively Hill 1 valve. Now it needs to be - the actual flap valve is gone, and that's what we're doing with this magnetic sphincter augmentation. We are going to put it around the esophagus, and augment the lower esophageal sphincter which has been destroyed basically. So we see the GE junction right there, which is exactly what you want. I'm gonna take a photo kind of pre-LINX. Okay, that's that. Everything stays underneath the diaphragm on maximal insufflation, which is as bad as it's gonna get. He does have a little bit of gastritis, as you can see, which is expected. He also recently was diagnosed with Celiac, so he was dealing with that. I'm going to pull this back, and we don't want anything in the esophagus when we're doing this. So I'm gonna pull it back and we're gonna park it, and I'm gonna park it at about 25, 'cause we know the GE junction was at 40, or we know the hiatal closure was at 40, and the GE junction was at 43. Okay, so let's get the needles out. Okay. By the way, Elaine, we're 20 minutes from being done. All right. In this case, I'm actually gonna leave the Penrose, and we're gonna put it in that retroesophageal window. Yeah, I'm gonna put it in that retroesophageal window we created earlier. Hmm, I will... Just make it easier for the sizer to go through. So we created that retroesophageal window. This is where the LINX is gonna be held in place. I'm just putting this here just for ease of putting the sizing device. All right, so make sure everything looks good. That looks good. Anterior vagus again, posterior vagus, looks good there. It's gonna go right about there. All right, so we have the sizing device. This is just basically magnets, a magnetic... Well, sizing device. So it is going to go around and I'm gonna use this. So we wanna go around the esophagus, and what this does is going to approximate what size we need, what size of LINX device we want, how many beads do we want on the LINX device. So we want to lay nicely around the esophagus, without being too tight, but not too loose. So we're coming down, we're looking at a 17 right now. It's a 16, 15. 15 seems to... See how it rolls a little bit? Then it doesn't seem too tight. 14. Ah, it doesn't look too bad either. 13, 12, so pops at 12. So informally, we use three above pop. So whatever it pops at, you go three above that. I test three or four times at least, again, just to make sure that everything is nice. Make sure there's nothing in there, or in the retroesophageal window. There's no extra fat or anything in there. So we're at 15, 14. 14, you know, honestly, it doesn't look terrible, but there's little dimple. 13, 12. Again, pops at 12. We're gonna do this one more time. If I'm going to err, I'm gonna err a little bit on the size of being a tiny bit bigger. So that again, that's a 15. No that's a 16, sorry, and that looks a little loose. 15, still rolls a little bit, but nice and loose. But not, you know, not too tight but not too loose. 14 just seems like it might be a little bit tight. 13, 12. Pop to 12 every time, we will do a size 15, please. The risks associated with this are mostly dysphagia, so I do want to - I wanna make sure we do as good a job at getting everything in, but not causing any dysphagia.

CHAPTER 9

So the size 15 corresponds to the number of beads there are on the device. This is titanium and rare earth magnets. The idea is it goes around the esophagus and expands when somebody swallows and then contracts again, because they're magnets, once the patient's finished swallowing, to prevent reflux. Just out of safety, I'm going to count the beads carefully. So, one, two, three, four, five, six, seven, eight, nine, 10, 11, 12, 13, 14, 15. 15 beads. Robotically, there's not a great way to do this. So I'm going to basically pop the cap here to get it in. Three, two, one. So, LINX is in. Okay, so... Pass this behind to ourselves, and there's a clasp that goes on it. So, I'm gonna be careful of the magnet. So I just grab the knots, grab the knot, and I like to park this here. You can see there's a little clasp, and it's gonna match up with the clasp on the other end, you can see that. So, I'm gonna park this here, and I swing up, hang around like that. And then on the robot it's really easy, because you can just grab and match it up. Laparoscopically, you have to work a little bit. And sometimes you do robotically as well. So you see there, the grooves have met. They're in the groove, and then we just clasp it. So it is difficult to tell, but it's sort of a... There's two windows and it becomes one window. I double check by grabbing both of these and pulling, and you can see, everything is laying nicely. It doesn't look too tight, it doesn't look like there's anything tight around. The beads are all closed. As you see as food goes down, the beads will expand, and then they tighten back up. There's gonna be elastic scar tissue that forms around each one of these beads so you don't have to worry about the vagus nerve getting caught in there. And the elastic scar tissue is formed because they have a diet of eating about every hour while awake for the first couple weeks after surgery. So we cut these sutures. And we will get the Penrose and everything out. Let me just set that there. Grab the Penrose, and you can go ahead and come out with the Megacut. So you see we have the LINX, or magnetic sphincter augmentation laying nicely just above the GE junction. We have a retro-vagal window so it doesn't slide too much. We have good hiatal hernia repair. We'll do this next, then the Penrose, then I'm gonna scope one more time, we'll get the liver retractor out and we're done.

CHAPTER 10

So it's parked at 25, we're gonna go back down. We're gonna see again, hiatal closure, at really 39 I'd say. Going down through the LINX. You wanna feel a slight pop of the LINX as it goes through, which I do, we just feel it on the scope. Just a little pop as the LINX opens up, and you can see on the screen, the LINX as the camera goes down, those LINX beads open up just a little bit, and that's really what you want. You want like one bead separation as it goes down. So again, so the pop is here, and then the GE junction is here. So the pop is at about... Or the GE junction that gives about 43 centimeters. So we've got three to four centimeters of the length, depending if - a little bit of sliding. Back in the stomach, we're gonna do retroflexion. We saw before, that we could see the GE junction but it wasn't a very robust Hill valve. So here you should be able to see after the sphincter augmentation, a really robust... You see that extra pillar. That's really what the original flap valve should look like, and what this looks like after full insufflation. So that is really reefed up, and looks a lot better than it did before, and that's what that LINX does. Forever. Ideally. Okay. There we are. We're gonna desufflate. We'll get the liver retractor out, and then - there's no bleeding, so we don't have to do anything else. Again, LINX shows us in good position above the GE junction and under the diaphragm. All right, scope is out.

CHAPTER 11

So Cathy, you okay getting the liver retractor out? If you leave one in, I can help you. Yeah, if you want to leave that in I can help. If you want to take it out, that's fine. Okay, perfect. A little bit of schmutz in there, but that's okay. I will check the site. All looks good. Go back to camera down, check the site again. No signs of bleeding. Everything looks good. All right, we only used eight-millimeter ports so we do not have to close anything. So we can go ahead and undock the robot and we are done. We'll do closure. Robot is coming out, excellent. And then once it's out, Elaine, you can flatten, but we'll wait.

CHAPTER 12

So we make sure all the air is out, all the CO2's out, and then we close with 4-0 Monocryl suture, and we give local anesthesia at the end as well.

CHAPTER 13

All right, so we have completed the case. Everything went very well. We chose a size 15 LINX for this patient, and as you could see, it showed that it was not too tight and not too loose around the esophagus. When we placed the endoscope through the GE junction and into the stomach, you noticed that the beads separated. Your one to two bead separation on entry of either food or the EGD scope into the stomach. Everything went very well. There were no complications. Of note, this was a slightly larger hernia than was originally described in the papers and in the indications for the magnetic sphincter augmentation. So initially it was a hernia under three centimeters. We did choose one that was about five centimeters. However, this was a young patient who was very healthy. He had normal manometry preoperatively, and I felt he would be very conducive to this operation. He also preferred the magnetic sphincter augmentation because it allowed him the ability to vent. So the ability to belch and to be able to vomit afterward, because belching was a large part of his reflux mechanism and sort of the reflex to the reflux in terms of swallowing more air. So the procedure went very well. It was, again, and as I said, a larger mediastinal dissection. I do like to extend my mediastinal dissection as high as I possibly can. So you notice that we went past, we went superior or cranial to the inferior pulmonary vein. If I can, I'll get all the way up to the azygos vein. I really want to keep everything under no tension, and I want to prevent the possibility of a recurrent hiatal hernia in the future. It's usually 10% recurrence rate at 10 years, and that is with either Nissen data or with this LINX data. So fundoplication or magnetic sphincter augmentation. Overall, I feel it was placed well. It was placed, you know, around the - between the esophagus and the vagus. As you noted in the video. The hiatus was noted at 39 centimeters. The GE junction was noted at 43 centimeters. So we had four centimeter intraesophageal length, which is exactly what we want, and the LINX device was above it. Again, the beads separated as the endoscope went through into the stomach and the beads came back to normal after desufflation, and after the endoscope went through the stomach. Over time, each one of those beads is going to get a piece of elastic scar tissue around them. So the postoperative course for this patient is, he will eat a bite of solid food every hour while awake for the first two weeks. This can be, you know, yogurt or a couple of crackers or a piece of cheese or something, just to be able to get through the LINX, open those beads and close them again, so that the scar tissue that is formed is elastic. If they do not do this, there can be some inelastic scar tissue that forms, and that prevents the beads from opening, and that can cause them postoperative dysphagia. There is about a 4% removal rate for these procedures, and it's usually due to persistent dysphagia. We have a difficult way of knowing outside of preoperative manometry how patients will do, but there's a small subset of people who just do not do well with a foreign body around their esophagus. 96% of patients do well though and are off their PPIs, and eating and drinking normally without any signs of reflux at 10 years. So I do believe this patient will do very well, and I don't anticipate any further need for operations in the future.