Laparoscopic Toupet fundoplication - general and visceral surgery

One midline skin incision markedly superior to the umbilicus. After having introduced the Verres needle and checked its correct position, establish the pneumoperitoneum.

Introduce the laparoscope with attached camera through a 5 mm/10 mm trocar. Perform a diagnostic laparoscopy. Introduce 4 epigastric trocars under direct visual control.

Lift up the left hepatic lobe with the exploratory probe and tense the stomach with the Babcock clamp. Incise the flaccid portion of the lesser omentum with the harmonic scalpel.

Now expose the right crus of the diaphragm. Via the anterior commissure then proceed anteriorly to the left crus and expose it as well. This opens up the mediastinum anteriorly.

At the level of the splenic hilum transect the gastrosplenic ligament and short gastric vessels along the greater curvature up to the superior pole of the spleen and further on to the left crus of the diaphragm, until the gastric fundus has been freed completely.

Now continue far into the inferior mediastinum and free the lower esophagus in circular fashion from its adhesions. When doing so, the posterior vagus nerve must be positively identified and left clinging to the esophageal muscles. Free the esophagus from inside the mediastinum until the region of the lower esophageal sphincter rests inside the abdominal cavity without any tension.

Perform posterior hiatoplasty with two z-stitches (non-absorbable braided suture size 1). Esophageal passage must be sufficiently wide and patent.

Tip: Patency may be calibrated with a 40F stomach tube.

Pull the part of the fundus close to the angle of His to the right. Now define the corresponding parts of the fundus with the shoeshine maneuver.

Clearly identify the anterior branch of the vagus nerve. With a running suture (non-absorbable braided suture size 2/0) first fixate the right ear of the fundus to the right side of the esophagus while sparing the anterior branch of the vagus nerve. Then fixate the right part of the fundus to the right crus of the diaphragm with another running suture (non-absorbable braided suture size 2/0).

Now fixate the left fundus cuff to the left side of the esophagus (non-absorbable braided suture size 2/0), resulting in a partial posterior 270-degree wrap (Toupet fundoplication).