Editing Anti-reflux surgery (section)

== '''Technique:''' ==

* Low lithotomy and steep     reverse Trendelenburg with surgeon between legs and assistant to patient's     left
* Access abdomen, ports centred     on GOJ
** 10mm LUQ optical, 10mm      epigastric, 5mm in RUQ and LUQ, then 5mm sub-xiphoid for Nathanson
** Place Nathanson liver      retractor
* '''Exposure and     reduction/repair of hiatus hernia''' ''(see separate topic for hiatus     hernia repair)''
** Mobilise oesophagus - need a      minimum 3cm intra-abdominal oesophagus
** Completely free oesophagus      at crus circumferentially
** Approximate crura      posteriorly and anteriorly
*** Checking size - either       ensure a 52Fr bougie can pass into stomach easily or just check by eye
*** Ethibond sutures
* '''Fundoplication:'''
** May need to mobilise fundus      by dividing short gastric arteries
** 360 degree
*** Posterior aspect of the       fundus marked with a suture 3cm distal to GOJ and 2cm off the greater       curvature
***
*** Posterior fundus passed       behind the oesophagus from left to right
*** Anterior fundus on the left       side of the oesophagus is then grasped (2cm from the greater curvature       and 3cm from GOJ), and both portions of the fundus are positioned on the       anterior aspect of the oesophagus
***
*** First suture is placed,       then a 52Fr bougie passed into stomach, and the fundoplication is       completed (3 or 4 interrupted permanent sutures)
*** Remove the bougie
*** Secure the fundoplication       to the diaphragm with right and left coronal sutures (prevents slipping       and herniation into mediastinum)
** Toupet fundoplication
*** Wrap 180-270 degrees       posteriorly
*** Pull fundus posteriorly
*** Initial       gastro-oesophago-phrenic suture
*** 2x oesophago-gastric       sutures
*** Suture to left crus
** Dor/Thal fundoplication
*** No need to disrupt the       posterior attachments of the oesophagus
*** Fold fundus over the       anterior aspect of the oesophagus
*** Anchor to the hiatus and       oesophagus
* '''Short     oesophagus'''
** Need minimum 3cm      intra-abdominal
** First step - mobilisation in      posterior mediastinum - can get enough length in most patients
** Second step - vagotomy - 2cm      per side - did not seem to lead to delayed gastric emptying according to      Sabiston
** Third step - stapled wedge      gastroplasty - almost never needed
***