In thin patients, this is a minimal structure that is easily entered and contains few vessels. However, in overweight patients, the gastrohepatic ligament has significant fatty substance that requires a careful dissection. Exposure for the surgeon may be improved with a careful grasping and elevation of the cut hepatic edge of the ligament. Careful dissection is essential, as some patients may have an aberrant left hepatic artery in this region (Figure 7, danger arrow). This vessel must be identified and preserved. With Babcock traction on the lesser curve of the stomach, the peritoneum over the right crus muscle is entered. This crus is cleaned posteriorly. The hiatal defect will appear behind the esophagus and the posterior “V” or fan-shaped fusion of the left and right crus will become apparent.
The final peritoneal dissection occurs just anterior to the esophagus across the connecting arch of the diaphragmatic muscle that joins the two crus muscles (Figure 8). Once this area has been cleared, the esophagus is mobilized further with careful preservation of the left anterior and right posterior vagus nerves. About 2 to 3 cm of the esophagus should extend into the abdomen. This dissection is performed using gentle elevation and lateral retraction of the gastroesophageal junction with the shaft of an instrument. Dissection should not proceed blindly into the hiatus or above the superior or cephalad top of each crus, as a pleural opening may be created. This usually does not present a significant problem, as the positive-pressure endotracheal ventilation has greater pressure than the CO2 inflation pressure within the abdomen. In some cases, however, the opening may be repaired with a suture, and a chest tube may be required.
With experience, most surgeons can estimate the extent of the hiatal opening that needs to be closed. In general, two sutures are required to join the two crus muscles posteriorly. The 10-mm endoscopic suturing instrument containing a 0 non-absorbable braided suture is introduced through the left midsubcostal port. The first pass is taken through the left crus, going from lateral into the hiatus (Figure 9). The needle-holding jaws are closed and the instrument control is shuttled, passing control of the needle to the medial jaw within the hiatus. The instrument is opened and the needle and suture are pulled through the left crus. In free space, the endoscopic suturing instrument is closed and the needle is shuttled back into the lateral jaw. The same suturing process is then repeated, passing the needle and suture through the right crus from hiatus to the patient's right. A knot with four throws is created in the routine manner and the suture is cut with endoscopic scissors. A second suture in the crus is usually sufficient (Figure 10).
The floppy 360-degree wrap is created after first determining that there is sufficient gastric mobility. The upper greater curvature of the stomach is passed behind the esophagus. A pair of instruments grasp the stomach in the proposed wrap areas and a “shoeshine”-like maneuver from side to side is performed (Figure 11). It is verified that there is more than enough gastric mobility to create a tension-free loose wrap over a several-centimeter zone. This maneuver may reveal the need for further division of short gastric vessels along the lower aspect of the greater curvature of the stomach. The orogastric tube is withdrawn and the anesthesiologist passes a very large 56 to 60 French esophageal dilator. It is essential that the tapered tip of this dilator is passed fully into the stomach so as not to undersize the esophagus. Some surgeons prefer to use a fiberoptic lighted dilator to verify the gastric placement. With the dilator in place, the adequacy of the hiatal opening is verified by examining the posterior approximation of the right and left crus. Additionally the right and left gastric wraps are tested for sufficient length to cover a zone of 2–3 cm or so of intra-abdominal esophagus (Figure 12). The wrap usually requires three sutures that begin distally (Figure 13). The last or most cephalad suture is placed as a triple bite (Figure 14A), the midportion of which includes a seromuscular partial-thickness component of the esophagus. A final suture anchors the right wrap to the right crus (Figure 14). These last two sutures are intended to lessen the chance of migration of the wrap.
The fascia of the 10-mm port sites are sutured with one or two delayed absorbable 00 sutures. The skin is approximated with fine absorbable subcuticular sutures. Adhesive skin strips and dry sterile dressings are placed.
Gastric decompression with a nasogastric tube is usually not required. Clear liquids are given as tolerated and the diet is advanced to soft, easily chewed foods. Some patients may experience transient dysphagia, which can be controlled with dietary changes. Proton pump inhibitors or other antacid regimens may be continued for 1 or 2 weeks.