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The effectiveness of the fundoplication depends upon the adequacy of the “wraparound” procedure. It is important to mobilize the fundus of the stomach by ligating four or five gastrosplenic (short gastric) vessels (Figure 5). This must be done very carefully to avoid splenic injury. Some prefer to ligate the vessel on the gastric side by a transfixing suture that includes a portion of the gastric wall. When the exposure is quite difficult, the vessels on the splenic side may be ligated by the application of silver clips. A rubber tissue (Penrose) drain is placed around the esophagus to provide downward traction on it (Figure 6). A large gastric tube (Ewald) or the (Maloney) 56-60 French rubber esophageal dilator is inserted into the esophagus before the procedure to prevent undue compression of the esophageal lumen. The right hand is introduced behind the fundus of the stomach to test the adequacy of the gastric mobilization (Figure 6). It is absolutely essential that sufficient fundus be freed up to permit an easy wrap around the lower esophagus. As downward traction is maintained on the esophagus with the rubber drain around the esophagus, the right hand holds the gastric wall around the esophagus. One or more long Babcock forceps are applied to the gastric wall on either side of the esophagus (Figure 7). Traction on both sets of forceps makes it unnecessary for the hand of the surgeon to be in the wound. The anterior and posterior gastric walls are approximated with interrupted sutures of 00 silk (Figure 7). Several interrupted sutures are usually adequate along a 2- to 3-cm zone. Some prefer to have the highest suture include a superficial bite in the esophageal wall and the gastric wall as insurance against the sliding upward of the “wraparound” (Figure 8). Additionally, many place an anchoring suture between the gastric wrap and the crus. This prevents upward migration of the gastric tunnel around the esophagus. The large dilator in the esophagus prevents undue constriction of the esophagus. After the traction rubber drain and esophageal dilator are removed, the surgeon introduces the index finger or thumb upward under the plicated gastric wall. No undue constriction must exist nor further mobilization of the greater curvature of the fundus be provided. The area of the esophagus is finally inspected to be certain the vagus nerves have not been injured. A pyloroplasty should be added if the vagotomy is performed, and a temporary gastrostomy may be carried out with fixation of the anterior gastric wall to the overlying peritoneum. The dilator is removed ...

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