Laparoscopy is the standard approach. Recently 3D cameras are being used to improve deepness perception to help with the maneuvers in a narrow space.
A total of 4 trocars were used, one of 12mm in supra umbilical position for a 3D camera with flexible tip, two of 11mm (one on each flank) and one of 5mm at the epigastrium.
A liver retractor is used to separate the left lobe.
In this case, there is a considerable hiatal hernia and the first maneuver is to reduce the stomach into the abdomen. The dissection is made from left to right, individualizing the fundus from the crura and the hernial sac.
The Thunderbeat™ is used to section the attachment of the fundus to the left crura, the goal is to expose the hiatus for future closure and allow posterior fundoplication.
The right crura is individualized and anatomical structures become more clear. The posterior wall of the gastroesophageal junction is free and a silastic drain is passed through this space to improve the traction and help with the dissection of the distal esophagus. This is the part of the surgery where a 3D visualization system is more important.
Careful maneuvers must be done to avoid pleural or cardiac lesions. The hiatal defect is closed with separated knots of a polyfilament suture, for this case two stitches were made.
The shoe shine maneuver is performed to ensure that the fundus slides freely posterior to the esophagus and is of an appropriate length. Another important concept is to build a floppy Nissen to prevent obstructive symptoms at the postoperative period.
The fundoplication is accomplished with separated knots that involves the fundus, the anterior wall of the esophagus and the fundus again.
Some surgeons use a buggie during this part of the procedure to respect the esophageal lumen.