The patient is positioned on the operating room table in supine position. The patient’s arms can either be tucked or outstretched to ~80° and secured on padded arm boards. We prefer to abduct the legs on flat-padded split leg boards to minimize the possibility of neurovascular injury. The patient should be well secured in order to achieve steep reverse trendelenburg, which will help in displacing organs from the hiatus. The surgeon can either stand between the patient’s legs, or on the patient’s left depending on preference. When only one assistant is available, we find that it is best for the surgeon to stand on the patient’s left with the first assistant in between the patient’s legs (Fig. 10.2).

The initial port site is placed 12 cm below the xiphoid process and 2.5 cm to the left of the midline using either an open or closed technique of entry as per surgeon preference (Fig. 10.3). It is important that this port not be placed too inferior or the mediastinum may be difficult to visualize. This initial port is typically a 10–12 mm for entry of a 10 mm 30–45° laparoscope. We prefer a 10 mm scope for optimal visualization. After entry, the abdomen is explored looking for iatrogenic injury and presence of intra-abdominal adhesions that would hinder subsequent port placement. A 5 mm port is then placed 15 cm from the xiphoid and 2–3 cm inferior to the right costal margin for the liver retractor. The left lobe of the liver is retracted anteriorly using the preferred liver retractor of the surgeon and secured to the operating room table. A 5 mm port is then placed between the first two ports and used by the assistant to retract for the surgeon. With the liver retracted, a 5 mm port is placed just inferior to the xiphoid and will serve as the surgeon’s left hand. Lastly, a 5 mm port is placed 10 cm from the xiphoid and 3 cm below the left costal margin for the surgeon’s right hand.

Using an atraumatic grasper, the assistant surgeon grasps the anterior epigastric fat pad and retracts the stomach downward and towards the left lower quadrant. The surgeon divides the hepatogastric ligament along the edge of the caudate lobe, preserving the nerve of Laterjet, and any aberrant left hepatic arteries if present, using ultrasonic or bipolar shears (Fig. 10.4). If a giant paraesophageal hernia is present, it is often better to gain access to the mediastinum anteriorly in order to avoid structures, such as the left gastric artery, that may be herniated just inside the right crus. The right anterior phrenoesophageal ligament and peritoneum overlying the anterior abdominal esophagus is fully divided staying superficial in order to avoid injury to the anterior vagus and esophagus. Careful mediastinal dissection is then performed by sweeping the esophagus away from the right crus. At this point, it is important to identify the posterior vagus and sweep it towards the esophagus, often best achieved by the surgeon retracting the right crus laterally with his or her left hand (Fig. 10.5). The left hand can then elevate the anterior crus and the mediastinal dissection is continued circumferentially in a clockwise fashion until the left and right crural limbs are freed anteriorly and posteriorly. This mediastinal dissection is performed with a combination of sharp and blunt dissection until 3–4 cm of tension-free intra-abdominal esophagus is freed. Meticulous attention is needed to avoid inadvertent vagal or esophageal injury. The hiatus is then closed posteriorly with interrupted permanent suture. Hiatal closure can be tight when repairing a large hiatal or paraesophageal hernia, or preferably somewhat lax when performing a fundoplication, particularly in a patient with a motility disorder such as achalasia.

The short gastric vessels are ligated along the upper third of the gastric fundus (from the inferior pole of the spleen proximally, or approximately 10–15 cm inferior to the Angle of His) allowing free rotation of the gastric fundus without tension. A retroesophageal window is created and the posterior wall of the fundus is grasped and dragged behind the posterior vagus and posterior distal esophagus. A “shoeshine” maneuver is performed to confirm that no twisting of the esophagus is present (Fig. 10.6). If the fundus is grasped and pulled correctly, it should lie to the right of the esophagus without retracting back when let free. The assistant now grasps the gastric fundus retracting it towards midline, which in turn retracts the esophagus, exposing the posterior hiatus (Fig. 10.7). A posterior gastropexy is performed by suturing the posterior fundus to the inferior crus with one to three interrupted permanent sutures. A bougie is then placed carefully and under laparoscopic vision if desired. The size of the bougie will vary based on the diameter of the esophagus and whether or not a myotomy has been performed; with a myotomy, we tend to use a smaller bougie (48–52Fr), whereas without a myotomy, a larger size bougie (54–60Fr) can be placed based on visual estimation of the patient’s esophagus and degree of dysmotility or reflux. Two coronal stitches are placed at 10 and 2 o’clock securing the shoulders of the fundus to the diaphragmatic hiatus. Next, two to three interrupted sutures are placed from the esophagus to the left and right fundus (Fig. 10.8). If a myotomy has been performed, the edges of the fundus should be sutured to the muscle edges which will in turn splay the myotomy open.

The patient is positioned on the operating room table in supine position, with their arms tucked. After intubation and induction of general anesthesia, a urinary catheter is placed and an upper midline incision is made from subxiphoid to supraumbilical. The surgeon may use any retraction system they prefer with the goal of optimal exposure by retraction of the xiphoid and inferior ribcage forward. As with any laparotomy, retraction is needed to separate the abdominal fascia and wound edges. Raising the head of the bed 20°–30° helps to cause the small intestine and omentum to fall inferiorly creating maximum hiatal exposure.

Hiatal dissection begins by retraction of the left lobe of the liver forward to expose the esophageal hiatus. At this point it may be necessary to divide the left triangular ligament of the liver. The phrenoesophageal ligament, comprising a superficial peritoneum and deeper fibrous layer is incised circumferentially around the esophagus to display the edges of the two hiatal pillars. Attention to detail is required during this dissection to prevent injury to the left and right vagal trunks that are found anteriorly and posteriorly respectively. Additionally, the surgeon must be meticulous during this dissection to avoid iatrogenic esophageal perforation.

When the distal esophagus is thoroughly freed from its surroundings, umbilical tape or a Penrose drain is placed behind and around the esophagus to retract it anteriorly exposing the posterior hiatus. The stomach is retracted inferiorly to expose 5–6 cm of distal esophagus. The open fundoplication is performed in a similar fashion to the laparoscopic technique (see previous).

In the original description, Toupet did not include a hiatal repair or closure, but if the hiatal orifice remains too large after the technique described above is performed, we recommend placing sutures across the hiatus to prevent slippage of the fundus.