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Figure 10-1 Grade I flap valve. Note the ridge of tissue, which is closely approximated to the shaft of the retroflexed endoscope. It extends 3 to 4 cm along the lesser curve.

Figure 10-4 Grade IV flap valve. There is no muscular ridge at all. The gastroesophageal area stays open all the time, and squamous epithelium can often be seen from the retroflexed position. A hiatal hernia is always present, as is esophagitis.

Figure 10-5 The relationship of the lower esophageal sphincter (LES) to the gastroesophageal valve (GE Valve). The sphincter resides inside the valve; aids the valve in discriminating among gas, liquid, and solids; and helps prevent reflux. The arrows are pressure vectors demonstrating that increased intragastric pressure closes the valve.

Esophagus

Figure 10-6 The phrenoesophageal bundles are taken close to the diaphragm so that they can be used in the repair.

Anterior phrenoesophageal bundle

Figure 10-7 Sutures are taken through the anterior and posterior phrenoesophageal bundles.

Figure 10-7 Sutures are taken through the anterior and posterior phrenoesophageal bundles.

Pfirenoes&phageal bundle

Figure 10-8 Four sutures are placed in the anterior and posterior phrenoesophageal bundles and carried through the preaortic fascia.

MecEan arcuale ligament

Celiac artery

Aorta

Anterior ph renoesaphageal bundle

Posterior phreooesophageal bundle

MecEan arcuale ligament

Posterior vagus nerve

Preaortic fascia

Anterior vagus nerve

Figure 10-9 A single knot is placed in the top two sutures, which are then clamped with two long hemostats.

Figure 10-10 All four sutures are tied, and a final pressure measurement is taken.

Figure 10-11 The cardiodiaphragmatic sutures complete the repair.

Fascia

Figure 10-12 Trocar placement.

Figure 10-12 Trocar placement.

Acknowledgments

We wish to acknowledge the help of Hope Dumais, Bette Glass, and Wm. Dudson Bacon.

References

1. Hill, L.D., Aye, R.W., and Ramel, S.: Antireflux surgery. A surgeon's look. Gastroenterol. Clin. North Am., 19:745, 1990.

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