Fig. 3

Operative technique. a On the stomach’s greater curvature, the gastrocolic ligament is incised along the avascular area between the left and right gastric omentum vessels, and the gastric fundus is lifted vertically toward the cardia to protect the vagus nerve. b The cardia, lower esophagus, and diaphragm are exposed, and the confluence of the left and right crus of the diaphragm is revealed. The retroperitoneum is incised at the left and right crus of the diaphragm, and the lower esophagus is dissociated for approximately 3–5 cm. The gastric fundus and the posterior wall of the esophagus are fully dissociated from the upper spleen. c Non-absorbable intermittent sutures are used at the left and right crus of the diaphragm to reconstruct the esophageal hiatus (diameter: approximately 1.5 cm). d The surgeon inserts the mesh and fixes it to the crus of the diaphragm with staples if the HH size is > 5 cm or the diaphragm on both sides of the defect is weak. e A small incision (approximately 2–3 cm) is made above the bifurcation of the anterior vagal trunk and the hepatic branch of the vagus nerve. This region is the avascular area of the lesser omentum. f The fundus of the stomach is rotated around the posterior aspect of the abdominal esophagus to the right anterior aspect of the esophagus (using non-absorbable sutures for 2 or 3 stitches intermittently) and then fixed to the right crus of the diaphragm and the right side of the esophagus. The left side of the gastric fundus is also sutured to the anterior esophagus and the left crus of the diaphragm, which avoids vagus nerve injury. Finally, the surgeon completes the fundoplication