Proper retraction of the gastrosplenic omentum facilitates the initial steps of short gastric division.
Dissection of the left crus. The left crus is dissected as completely as possible, and the attachments of the fundus of the stomach to the diaphragm are taken down.
Initial dissection of the esophageal hiatus. The right crus is identified and dissected toward its posterior confluence with the left crus.
Laparoscopic exposure of the esophageal hiatus. A fan-type retractor (placed through the right subcostal port) elevates the left lateral hepatic segment anterolaterally. A Babcock clamp (placed through the left lateral port) retracts the stomach caudad. T
Trocar placement for laparoscopic antireflux surgery. Five 10-mm trocars are generally used, but the two lateral retraction ports, and occasionally others can be downsized to 5 mm with appropriate instrumentation.
Patient positioning and room setup for laparoscopic fundoplication. The patient is placed with the head elevated 45 degrees in the modified lithotomy position. The surgeon stands between the patientâs legs. One assistant, on the surgeonâs right, retracts