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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.
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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.
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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 ...