Position the patient in the modified lithotomy or split leg position with both arms extended. Perioperative antibiotics and SQ heparin should be administered. After padding all pressure points and securing the patient, a total of five laparoscopic ports using a combination of 5-mm and 10-mm trocars are positioned as follows. One supraumbilical 5-mm port to accommodate a 5-mm 30-degree laparoscope. Place this port about halfway between the xiphoid and the umbilicus, just slightly off to the left of the midline to avoid the falciform ligament. Place a 5-mm port at the right anterior axillary line, about 3 to 4 inches below the costal margin to accommodate a self-forming liver retractor.

Inspect the abdomen in the usual fashion. Place a liver retractor to elevate the left lobe of the liver to expose the hiatus and secure it to a stationary holding device (Fig. 54.2). In most patients, the liver retractor should provide adequate hiatal exposure and the left triangular ligament can be left in place. Next, position a 5-mm right and a 10-mm left subcostal port along the midclavicular lines. These are used as the main dissecting ports and should be placed as cephalad as possible to allow for dissection in the mediastinum. Place the 5-mm right subcostal port just to the left of the falciform ligament and below the lower edge of the elevated left liver lobe. Lastly, place a 5-mm port in the left anterior axillary line for the assistant.

If an additional port is needed for retraction, a second 5-mm port may be placed in the left lower quadrant region, just slightly lower than the camera port. The surgeon stands in between the legs to allow for ergonomic dissection, while the assistant stands on the left side of the table as shown in Chapter 46, Figure 46.1C.

Using atraumatic graspers passed through the main dissecting ports, gently reduce the easily reducible portion of the herniated stomach back into the abdominal cavity. The assistant provides lateral retraction to the herniated stomach while the surgeon divides the gastrohepatic ligament using the Harmonic scalpel (Fig. 54.3). The gastrohepatic ligament is the avascular tissue that joins the lesser curvature of the stomach to the liver. In 10% to 15% of the population, a replaced or accessory left hepatic artery arising from the left gastric artery may be present within the gastrohepatic ligament. It is easily identified as the vessel that travels horizontally within the gastrohepatic ligament. Oftentimes, the gastrohepatic ligament can be divided with the Harmonic scalpel, cephalad to the aberrant left hepatic artery. This maneuver will allow the artery to fall away from the surgical field while maintaining exposure of the hiatus. Take care also to avoid injury to the left gastric artery, which lies just posterior to the gastrohepatic ligament.