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Minimally invasive fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), is one of the most common gastrointestinal diseases treated by physicians, with most patients being successfully managed medically. Patients with refractory or persistent disease may be treated using minimally invasive surgical techniques. Patients may also elect for surgical treatment of GERD to avoid the potentially deleterious effects of long term antisecretory [proton pump inhibitor (PPI)] use. Preoperative workup is critical to establish the presence of GERD, to rule out concomitant or alternative pathology, and to document the presence or absence of coexisting esophageal motility disorders. When the technical tenants are respected, laparoscopic fundoplication is a safe and effective treatment of GERD. The general principles involve adequate mobilization of the gastroesophageal junction and gastric fundus, high mediastinal dissection, and demonstration of adequate intraabdominal esophageal length. This is followed by secure closure of the diaphragmatic crura, as well as creation of a fundoplication to reinforce the typically hypotonic lower esophageal sphincter. The type of fundoplication used is typically influenced by preoperative manometry, presence of dysphagia, and patient age. Long term symptomatic relief, without the need for antisecretory medications, is achievable for the majority of properly selected patients. Postoperative morbidity and mortality are uncommon following laparoscopic treatment of GERD. The following manuscript describes our method for performance of both laparoscopic complete and partial fundoplication.