Nissen fundoplication - general and visceral surgery

After transverse incision at upper pole of the umbilicus establish pneumoperitoneum and then insert 10 mm laparoscope. Insert four 5 mm trocars under transillumination in a semicircle superior to the umbilicus, one each in the left and right medioclavicular and anterior axillary line. Work through both medial 5 mm trocars, while the left lateral trocar is used for the liver retractor and the right lateral trocar for a grasper holding the stomach. Anti-Trendelenburg position of the patient and OR Table tilted slightly to the left.

Lifting up the left hepatic lobe with a liver retractor reveals the esophageal hiatus. Dissection with the harmonic scalpel begins by incising the lesser omentum at the pars flaccida while simultaneously pulling the stomach up to the left to the free margin of the right crus of the diaphragm. Now expose the gastroesophageal junction at the right crus while evading the posterior vagal trunk.

Continue the exposure of the esophagus along the anterior commissure to the left side. Doing so will also expose the left crus of the diaphragm