Visualization of the aberrant vessel through what is usually a transparent hepatogastric ligament is critical, especially in light of the frequency of this anatomic vascular anomaly (Fig. 17-1A). Frequently, the vessel can be reflected out of the operating field while still maintaining full visualization and allowing takedown of the right phrenoesophageal ligament and dissection of the GE junction. A small-caliber aberrant left hepatic artery would strongly suggest this to be an accessory vessel; it could be ligated if necessary to obtain adequate access to the GE junction and phrenoesophageal ligament. However, a larger-caliber vessel (e.g., >3–4 mm in diameter) should be reflected out of the operating field and spared for the reasons mentioned previously (see Fig. 17-1B).

The operating surgeon must visualize both anterior and posterior vagal trunks during the dissection of the GE junction and takedown of the right, left, and anterior phrenoesophageal ligaments (Fig. 17-2A). Some surgeons actually insert the wrap inside of the vagal nerve trunks, making sure that both trunks have been clearly delineated. The anterior nerve can be tethered up close to the phrenoesophageal ligament and must be reflected back onto the esophagus anteriorly. The posterior trunk is most commonly injured when the retroesophageal window is created. Care must be taken to again reflect the nerve anteriorly onto the esophagus to prevent injury (see Fig. 17-2).

Intra-abdominal leak with peritonitis. The reported incidence for this complication is roughly 1%; however, it carries a mortality rate of greater than 20%, making it one of the most important and lethal complications of LNF.¹⁰ This complication has been well described in the literature. When looking at specific mechanisms of esophageal perforations, Schauer and associates¹⁰ identified the majority of injuries occurring from improper retroesophageal dissection. Obesity and large hiatal hernias were found to contribute to esophageal injury secondary to excessive fatty tissue in the periesophageal region that obscures tissue planes and complicates dissection. As with other complications of LNF, experience of the surgeon is a risk factor for this complication. Schauer and associates¹⁰ reported that 10 of 17 esophageal perforations identified collectively from several institutions occurred during the first 10 LNFs performed by each surgeon.

Retraction of the esophagus should be carried out only with Penrose drains around the GE junction (Fig. 17-3A) or with retraction bluntly such as with the endoscopic Babcock retractor (see Fig. 17-3B). Grasping of the esophagus or junction with the retractors as previously discussed will lead to a high incidence of linear tears within the esophagus and catastrophic outcomes (see Fig. 17-3C). Dissection should be performed away from the esophagus to minimize the risk of injury and devascularization. Retroesophageal dissection should proceed from right to left, anterior to the left crus of the diaphragm—dissection too superior can lead to pneumothorax secondary to pleural penetration, too anterior can lead to esophageal perforation, and too inferior may lead to gastric perforation. If a tear is suspected (and commonly, these may be linear through the longitudinal muscle and difficult to visualize), insufflation with the nasogastric tube proximal to this area, with distal occlusion using a noncrushing bowel clamp and saline over the esophagus and stomach inspecting for leak, has been shown in animal studies to be a useful modality. This may hasten diagnosis of occult injuries, which may decrease the morbidity of perforation injuries in the future.¹¹

Hypercarbia and increased airway pressures. Murdock and colleagues¹² studied over 900 laparoscopic cases to identify which patients were at risk for developing hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum. They concluded that longer operative times (>200 min), higher maximum measured end-tidal CO₂, a greater number of surgical ports, older patient age, and Nissen fundoplications all predisposed to hypercarbia-related complications during laparoscopy. Of note, the relation between LNF and hypercarbia was attributed to the length of the procedure (mean 227 min), which would increase the risk of pneumothorax/pneumomediastinum by 20 times based on procedure length alone.¹²

The close proximity of the right and left pleura (especially the left pleura) in the mediastinal dissection must be understood during mobilization of the esophagus to achieve abdominal esophageal lengthening. The dissection should push the pleura away from the operative field (i.e., in the lateral plane of the thoracic dissection). Commonly, in an attempt for the surgeon to stay off the esophagus, the dissection extends out too far laterally into the chest and the pleural space (Fig. 17-4).