After the fundus is free and the left crus completely exposed, the left phrenoesophageal membrane is incised, safely entering the mediastinum between the left crus and esophagus. The dissection is continued anteriorly and superiorly, dividing the peritoneum overlying the anterior aspect of the crus. This line of division is extended down to the base of the right crus. Only now do we divide the gastrohepatic ligament.
Most of the hepatic branches of the vagus and occasional hepatic branch of the left gastric artery can be preserved with this approach. The right phrenoesophageal membrane is divided, exposing the inner edge of the right crus. Another advantage of this technique is that because the decussation of the right and left crus is identified, a posterior esophageal window is created without dissection toward the splenic hilum. A 0.5-in. Penrose drain is placed in this posterior window and secured around the esophagus and two vagi with a clip or suture.
With the assistant tractioning from the Penrose drain, dissection of the intrathoracic esophagus is started. This is done until we achieve an intraabdominal esophageal length of at least 3 cm. Mobilization of the esophagus can usually easily be carried to the carina, and as a result we rarely lack enough intraabdominal esophagus to perform a tension-free repair. Careful attention should be paid to avoiding injury to the anterior and posterior vagal nerves, both pleural surfaces, and the aorta.
PRINCIPLES OF SUCCESSFUL SURGICAL ANTI-REFLUX PROCEDURES
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.