| Positionning of the patient |
  A nasogastric sump tube (Salem n° 18) is inserted. The patient lies supine, thighs fully abducted and slightly bent. The operation table has a 20° reversed Trendelenburg tilt. The surgeon stands between the patient's legs. The first assistant is standing on the patient's left side, the second assistant on the right side. |
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| Placement of trocars |
Five trocars are needed for the operation: a 10 mm trocar well above the umbilicus, a 5 mm trocar in the right subcostal area, a 5 mm trocar in the left subcostal area, a 10 mm trocar between the first and the third one, and a 10 mm trocar under the xyphoid process. They allow the introduction of: a 30° angled laparoscope, a liver retractor, a coagulation hook, and two grasping forceps.
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| Exposure of the esophageal hiatus |
 The second assistant retracts the left liver lobe thus exposing the esophageal hiatus. The right pillar is readily seen through the peritoneal covering of the gastrohepatic ligament.
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| Dissection of the esophageal hiatus |
- The lesser omentum is widely opened. Extra gastric vagal branches are as sacrified, if necessary for exposure. The right pillar of the hiatus can now be seen.
- The peritoneal sheet covering the phreno-esophageal ligament is incised.
- The incision is taken to the left where the phrenogastric ligament is reached and severed.
- The right pillar of the crus is dissected from top to bottom, until the lowermost part of the left pillar is reached. A forceps coming from the top trocar is now inserted in the angle between the right crus and the oesophagus. The stomach is pulled caudally and laterally. Localizing the left pillar is essential before any further dissection of the retro-esophagus is undertaken. The posterior vagus nerve is identified at this time. The retro- esophageal area is dissected well inside the abdomen, and, by doing this, the lowermost portion of the phrenogastric ligament is severed.
- The left pillar is dissected going upwards, care being taken not to injure the vagus nerve. While the esophagus is retracted away from the left pillar, dissection is carried out under direct vision.
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| Suture of the pillars |
 A needle-holder and 2.0 silk thread are introduced through a 10 mm trocar under the left subcostal area (3). The grasping forceps(E) is introduced in (2). |
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| Mobilization of the greater curvature and hemostasis of the short vessels |
 A grasping forceps pulls the stomach in its middle to the right. By countertraction a second forceps exposes the gastrosplenic ligament. The short vessels are isolated with a coagulation hook.
Hemostatic control is performed by placing clips. Mobilization of the greater curvature is carried out by severance of the upper-most (about five) short vessels. |
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| Luxating the wrap behind the esophagus |
 A forceps grasps the fundus at the greater curvature and passes it to a second forceps inserted behind the esophagus. This latter forceps pulls the fundus until it reaches the right side of the esophagus. The wrap stays in place by itself, without need to maintain it. |
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| Performing the 360° fundoplication |
 A 33 F Maloney dilator is introduced in the esophagus. By moving the wrap back and forth behind the esophagus one can make sure that no torsion of the luxated fundic wrap has occurred. Suturing is initiated only then. The interrupted sutures of 2/0 silk take a bite through the stomach, the anterior wall of the esophagus and the gastric wrap. The lowermost stitch does not include the esophageal wall. Five stitches are put in total. Before conclusion, the Maloney dilator is removed and a regular nasogastric tube is inserted. No external drains are left. |
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| Final aspect of the fundoplication |
 The nasogastric tube is removed on the first postoperative day; the integrity of the gastric wrap is checked by barium swallow and a liquid diet i |
