After pneumoperitoneum is established, usually by using the Veress needle in the left hypochondrium, the initial port is inserted in the abdominal cavity. Correct placement of the 8 mm camera port is of utmost importance. The typical supraumbilical port position is 12 cm caudad to the xiphoid and 2 cm to the patient’s right. For larger patients, port is placed 15 cm caudal to the xiphoid and 2 cm to the right. The distance might need to be re-adjusted especially if the procedure includes a large hiatal hernia repair [13].

The two 8 mm trocars for the robotic arms are placed on the same horizontal line and 8 cm lateral to the camera port in the left and right upper quadrant close to the mid-clavicular line. The third 8 mm trocar for the third robotic arm is inserted in the left anterior axillary line (Fig. 3.2). Depending on surgeon preference, a liver retractor could be utilized [5, 14].

Following port placement, the patient is placed in a reverse Trendelenburg position with an angle of >30° and the robotic cart is brought into the field. With the Si system, the robot must be parked at the head of the table, whereas with the Xi system, the robot can be parked at the patient’s side as this platform includes an overhead boom allowing the arms to rotate as a group into any orientation. This allows for direct access to the patient by the anesthesia team. The console and vision cart are located safely away from the robot to allow for adequate movement of the arms and adequate room for the anesthesia team. The monitor is either at the foot of the table or mounted on the wall depending on the operating room setup. Appropriate adjustments of the operating table might need to be applied to prevent obstruction of the Anesthesiologist.

The operation begins with a hiatal dissection. First, retract the anterior epigastric fat pad and the stomach downward and towards the left lower quadrant using a Cadiere grasper. The gastrohepatic ligament is divided, using the electrocautery hook (Fig. 3.3), along the edge of the caudate lobe and the dissection plane is moved cephalad until the junction between the right crus of the hiatus and the phrenoesophageal membrane is encountered. Extra care is taken to preserve the anterior vagus nerve and especially the nerve of Latarjet and any aberrant left hepatic arteries, if present, are divided between clips (Fig. 3.4).

The right anterior phrenoesophageal ligament and the peritoneum overlying the anterior esophagus are incised superficially in order to prevent any injuries to the esophagus or anterior vagus. This incision is extended to the left crus and the esophagus is peeled off the right crus providing access to the mediastinum. The posterior vagus is identified and preserved (Fig. 3.5) and the dissection is extended circumferentially and in a clockwise fashion within the mediastinum. If a hiatal hernia is encountered, the hiatus is fully dissected and the esophagogastric junction is reduced into the abdomen. Eventually, using sharp and blunt dissection, 4 cm of intra-abdominal esophagus are mobilized anteriorly and posteriorly from the right and the left crural limbs (Fig. 3.6). Complete excision of the sac should be performed. Subsequently, the robotic instruments are switched to two needle drivers and the hiatus is closed using non-absorbable sutures (2-0) (Fig. 3.7). Occasionally, a biologic mesh could be applied for reinforcement with promising results.

A point along the upper third of the gastric fundus (approximately 10–15 cm from the angle of His) is selected to begin ligating the short gastric vessels with an ultrasonic coagulator or bipolar vessel sealer (Fig. 3.8), in order to achieve mobilization of the fundus for the creation of the posterior partial fundoplication. The ligation is continued up to the level of the left crus.

The anterior epigastric fat pad is removed from the distal esophagus and cardia to ensure appropriate visualization of the exact placement of the wrap. A retroesophageal window is created and the posterior wall of the mobilized fundus is grasped and passed behind the posterior vagus and posterior distal esophagus in a “shoeshine”-like maneuver.

Permanent 2-0 sutures are used to secure the fundoplication. The two sides of the fundus are sutured together and a small bite of the esophagus is also taken. The wrap faces the patient’s right side in its final position. The first suture is most cephalad and is placed up on the esophagus at least 2–3 cm above the gastroesophageal junction. The next suture incorporates a small bite of the esophagus and is placed 1 cm distal. The third suture only incorporates the fundus and is placed another centimeter distal (Fig. 3.9).