Nissen fundoplication

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

Now dissect the distal esophagus in the mediastinum, with the harmonic scalpel and also bluntly, so that it is exposed circucumferentially over a distance of at least 10 cm; in the end 4 cm - 5 cm of the esophagus should rest tension-free in the peritoneal cavity. Dissection is markedly facilitated by encircling the esophagus and the posterior vagal trunk with a tape.

In order to prevent the subsequent hiatoplasty from constricting the terminal esophagus, insert a 40F gastric tube as bougie for calibration purposes. Adapt both crura of the diaphragm posterior to the esophagus by interrupted sutures whose knots are tied extracorporeally and then guided into proper position with a knot pusher (hangman’s knot). Use non-absorbable sutures size 0. The video clip demonstrates the first of a total of three sutures.

Note:

• The sutures must include the peritoneal cover of the crura of the diaphragm which frequently pulls back to the side during dissection.
• In very large hiatal hernia and upside-down stomach with the risk of volvulus, the hiatus may be constricted further by additional sutures anterior to the esophagus.