Position: supine with both arms tucked by the side. The head end of the table is kept 15 degree low to facilitate creation of pneumo-peritoneum and move the bowel away from the operative field. The monitor is positioned at the Head end of the patient. Legs are kept apart. Surgeon stands between two legs, camera assistant on right side of patient and assistant on left side of patient.
Painting and drapping performed
Pneumoperitoneum: The Veress Needle-5 cm above umbilicus in midline
10 mm 30 degree telescope inserted from 10 mm port 5 cm above umbilicus.
5 mm port at Palmers point, 5 mm in left lumbar region, 5 mm below xiphisternum, 5 mm working port right side of camara port in pararectal region.
Nathanson liver retractor inserted after removing epigastric 5mm port.
Dissection started from the gastrohepatic omentum , exposing the right crura.
Dissection proceeds posterior to abdominal esophagus from crura at the right side of hiatus and mobilising the lower esophagus from the mediastinum, also dissecting the posterior wall of esophagus exposing the left crura of the hiatus.
The short gastric vessels divided close to the stomach using harmonic scalpel and dissecting the left side of GEJ, and lower end of esophagus form the left side.
The hiatus closed with 3 interrupted sutures using 2-0 ethibond , making sure the hiatus is not too tight.
wrap of fundus is taken around abdominal esophagus.
A loose wrap should remain in place without undue tension and shoe shining maneuver is done. 2 interupted sutures with ethibond, taken on wrap to plicate it incorporating the wall of esophagus in the proximal most suture.
The wrap is finally fixed with the crura with one interrupted sutures.
Needles and any other foreign body is removed out and 10 mm port sheath closed with port vicryl no 1 under vision.
Skin of all ports closed with ethilon 3-0.
Dressing done.