Set up the room as described for laparoscopic fundoplication (see Chapter 53). The trocar sites and initial exposure are identical. Avoid extensive dissection posterior to the esophagus; rather develop just enough of a window behind the esophagus to allow a Penrose drain to be passed behind for traction (Fig. 55.1A,B). The remainder of the dissection is performed on the anterior and lateral aspects of the esophagus with downward traction on the Penrose drain.

Visually confirm the thickened, narrowed segment of esophagus and mobilize the esophagus into the abdomen until dilated proximal esophagus is seen.

Excise Belsey’s fat pad with electrocautery or ultrasonic shears (Fig. 55.1C,D). This allows unimpeded access to the gastroesophageal junction.

This dissection is largely confined to the anterior and lateral esophagus, in contrast to laparoscopic Nissen fundoplication, in which a more extensive dissection includes creation of an ample window behind the esophagus. As for Nissen fundoplication, dissection proceeds by outlining the crura of the diaphragm. These crura combine to form a muscular tunnel 2- to 3-cm long through which the esophagus and vagus nerves pass into the abdomen. There is considerable variability in the manner in which the fibrous and muscular parts of the esophageal hiatus form a sling around the esophagus; in actuality, dissection of the anterior and lateral parts of the hiatus is rarely affected by these variants. The median arcuate ligament crosses over the aorta just cephalad to the origin of the celiac axis and is not generally seen.

The left inferior phrenic artery runs along the left crus of the diaphragm and may give rise to an aberrant branch passing across the distal esophagus. The right inferior phrenic artery passes behind the inferior vena cava and is generally not encountered.