# Hiatal Hernia — GCMD Library living collection

Everything in the library about hiatal hernia — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 85 cited statements

## Episodes
### Surgical Management
- [Lap Nissen trinity narrated](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931) — video · 5:55 · [machine version](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931.md)
- [percuvance redo nissen](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993) — video · 5:16 · [machine version](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993.md)

### In-Depth Reviews
- [Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428) — video · 32:14 · [machine version](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=0) Diagnostic Testing for Gastroesophageal Reflux: Impedance Probes, pH Studies, and Upper GI Series (Ep 1)
- [5:57](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=357) Clinical Case: Three-Year-Old with Hiatal Hernia and Growth Failure (Ep 1)
- [10:51](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=651) Paraesophageal Hernia in a Ten-Month-Old: Type 2 Hiatal Hernia Management (Ep 1)
- [13:55](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=835) Gastroschisis Patient with Reflux: Laparoscopic Approach After Prior Abdominal Surgery (Ep 1)
- [18:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1136) Redo Fundoplication: Laparoscopic Versus Open Approach (Ep 1)
- [21:31](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1291) Comparative Outcomes: Laparoscopic Versus Open Fundoplication (Ep 1)
- [26:47](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607) Gastric Emptying and Pyloroplasty: Indications and Alternatives (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=0) Patient positioning, trocar placement, and initial adhesiolysis (Ep 2)
- [1:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=90) Division of gastrohepatic ligament and creation of retroesophageal window (Ep 2)
- [3:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=180) Division of short gastric vessels and fundal mobilization (Ep 2)
- [4:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=270) Crural repair and wrap construction (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=0) Port placement and Percuvance instrument insertion technique (Ep 3)
- [1:30](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=90) Takedown of previous fundoplication wrap (Ep 3)
- [2:30](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=150) Hiatal hernia repair with crural closure (Ep 3)
- [3:30](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=210) Creation of 360-degree fundoplication wrap (Ep 3)
- [4:40](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=280) Removal of Percuvance instruments (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Multiple-channel intraluminal impedance probes are the best test for quantifying the presence and severity of non-acid reflux over time." — Tim (clinical) [Ep 1 · 0:08](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=8)
- "Impedance probes are not readily available to all practitioners, particularly outside major centers, and even within the United States not all pediatric gastroenterologists perform them." (clinical) [Ep 1 · 0:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=38)
- "pH probes are more readily available and more commonly used than impedance probes for reflux evaluation." (clinical) [Ep 1 · 0:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=38)
- "Gastroenterologists report they can perform impedance studies in neonates, although they are rarely requested." — Tim (clinical) [Ep 1 · 1:04](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=64)
- "Surgical decisions to operate for reflux are typically based on clinical symptoms rather than objective testing." — Tim (clinical) [Ep 1 · 1:04](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=64)
- "In a study from the speaker's institution examining fundoplications and correlating upper GI studies with pH studies, the upper GI influenced management in 4% of cases." — Tim (epidemiological) [Ep 1 · 4:20](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- "Of the 4% of cases where upper GI influenced management, 80% were due to detection of malrotation." — Tim (epidemiological) [Ep 1 · 4:20](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- "The 4% rate of upper GI studies influencing management can be interpreted two ways: either 4% is significant enough to warrant routine pre-operative upper GI, or 4% is low enough that malrotation can be evaluated intraoperatively during fundoplication." — Tim (opinion) [Ep 1 · 4:20](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- "If pre-operative upper GI demonstrates malrotation in a patient being evaluated for fundoplication, management changes from fundoplication to Ladd procedure with proton pump inhibitors instead." — Tim (clinical) [Ep 1 · 5:26](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=326)
- "Upper GI studies can also detect duodenal web or duodenal stenosis in addition to malrotation, though malrotation was the most common reason for management change." — Tim (clinical) [Ep 1 · 5:47](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=347)
- "For a 3-year-old child who is eating orally, gastrostomy tube placement is not routinely indicated at the time of fundoplication." (clinical) [Ep 1 · 3:45](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=225)
- "Collis gastroplasty is not necessary for routine fundoplication with hiatal hernia repair in pediatric patients." (clinical) [Ep 1 · 2:24](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=144)
- "Pyloroplasty is not routinely performed at the time of fundoplication." (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- "For patients who tolerate nasogastric tube feeds without vomiting, gastrostomy tube alone may be sufficient without fundoplication." (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- "For patients who continue to vomit despite nasogastric tube feeds, fundoplication (Nissen) is indicated." (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- "In 2013, laparoscopic approach should be the default for fundoplication rather than open approach." — Tim (opinion) [Ep 1 · 6:43](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=403)
- "For type 2 (paraesophageal) hiatal hernias in children, fundoplication and hiatal hernia repair alone is adequate without gastropexy or gastrostomy tube." (clinical) [Ep 1 · 12:45](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=765)
- "Once a paraesophageal hernia is reduced and fundoplication performed, gastropexy does not appear necessary based on available data." (clinical) [Ep 1 · 12:45](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=765)
- "In gastroschisis patients being re-operated at 6 months of age, there are often not many adhesions present, making laparoscopic approach feasible." (clinical) [Ep 1 · 15:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=900)
- "For gastroschisis patients requiring fundoplication, left upper quadrant initial port placement via mini cut-down is preferred over umbilical access to avoid adhesions." (clinical) [Ep 1 · 15:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=900)
- "In neurologically normal 6-month-old infants with reflux, there may be justification to wait longer before proceeding to fundoplication since they may still outgrow reflux." — Tim (opinion) [Ep 1 · 16:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=998)
- "Laparoscopic approach can be successfully attempted even in patients with previous abdominal operations, as adequate visualization can usually be achieved with patience." (clinical) [Ep 1 · 16:59](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1019)
- "For redo fundoplication after prior laparoscopic Nissen, laparoscopic approach is preferred as visualization is often better than with open technique, even in the upper abdomen." (clinical) [Ep 1 · 18:11](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1091)
- "Laparoscopic anti-reflux operations are well-tolerated by infants with cardiac anomalies." — Tim (clinical) [Ep 1 · 22:16](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1336)
- "Wrap herniation above the diaphragm is NOT more common in the open group compared to laparoscopic (contrary to what might be expected)." — Tim (clinical) [Ep 1 · 22:16](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1336)
- "Postoperative bowel obstruction rates are significantly lower with laparoscopic fundoplication compared to open approach." — Tim (clinical) [Ep 1 · 22:37](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- "Traditional rates of postoperative bowel obstruction after open fundoplication were quoted as 5-10%." (epidemiological) [Ep 1 · 22:37](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- "Current estimated rate of postoperative bowel obstruction after laparoscopic fundoplication is approximately 1-2%." (epidemiological) [Ep 1 · 22:37](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- "For laparoscopic fundoplication, ports are placed higher in the abdomen, which may contribute to even lower bowel obstruction rates than general laparoscopic surgery." — Tim (clinical) [Ep 1 · 22:52](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1372)
- "Neurologically impaired children who develop adhesive bowel obstruction after fundoplication may present late and very ill because they have a closed-loop obstruction with inability to vomit." (clinical) [Ep 1 · 23:01](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1381)
- "Nasogastric tube trial is a useful diagnostic test: if a vomiting patient does well with NG feeds, they may only need a gastrostomy tube; if they continue to vomit with NG feeds, they will need fundoplication." (clinical) [Ep 1 · 23:35](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1415)
- "Nasojejunal tube trial is even more diagnostic than nasogastric tube, as tolerance of NJ feeds strongly predicts success with fundoplication." (clinical) [Ep 1 · 23:35](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1415)
- "For infants with hypoplastic left heart status-post stage 1 repair who have documented aspiration and recurrent desaturation events that cease with NJ feeds, fundoplication is indicated." (clinical) [Ep 1 · 24:23](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1463)
- "Indications for fundoplication in cardiac patients include recurrent aspirations, apnea-bradycardia-desaturation events, or failure to thrive, not simply the presence of cardiac anomaly alone." (clinical) [Ep 1 · 24:23](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1463)
- "In cardiac patients who are failing to thrive and need gastrostomy tube, performing fundoplication at the same time prevents creating an aspiration risk with G-tube alone." — Tim (clinical) [Ep 1 · 24:53](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1493)
- "PEG tubes that stick straight out are particularly cumbersome in cardiac patients who have sternal wires and atrial leads." — Tim (clinical) [Ep 1 · 24:53](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1493)
- "PEG tubes are not very appropriate for babies in general." (opinion) [Ep 1 · 25:19](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1519)
- "Cardiologists and pulmonologists are aggressive about recommending fundoplication for children with pulmonary hypertension or cardiac anomalies who are borderline feeders." — Tim (clinical) [Ep 1 · 25:50](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1550)
- "For cardiac patients too sick for fundoplication, primary GJ tube placement is an alternative, allowing jejunal feeding in hospitalized patients." — Tim (clinical) [Ep 1 · 25:50](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1550)
- "Fundoplication alone typically improves gastric emptying in most patients, eliminating the need for routine pyloroplasty." — Tim (clinical) [Ep 1 · 26:47](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607)
- "There is still a segment of patients with poor gastric emptying despite fundoplication who may benefit from additional interventions." — Tim (clinical) [Ep 1 · 26:47](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607)
- "Gastric electrical stimulation can effectively stop retching in neurologically impaired children with severe gastroparesis after fundoplication, with immediate cessation of retching." (clinical) [Ep 1 · 26:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- "Retching after fundoplication in patients with severe gastroparesis can loosen or undo the fundoplication wrap." (clinical) [Ep 1 · 26:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- "In the past when performing open fundoplications, gastric emptying studies were routinely checked and pyloroplasties were performed on neurologically impaired patients." (clinical) [Ep 1 · 26:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- "After switching to laparoscopic fundoplication and based on data showing it helps gastric emptying, routine pyloroplasty is no longer performed." (clinical) [Ep 1 · 26:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- "For gastric pull-up procedures (for lye stricture or esophageal atresia), pyloroplasty is performed." (clinical) [Ep 1 · 28:12](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1692)
- "For reverse gastric tube procedures performed in the neonatal period for esophageal atresia, pyloroplasty has not been performed." (clinical) [Ep 1 · 28:36](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1716)
- "Adult thoracic surgeons performing gastric pull-ups for esophageal cancer stopped doing pyloromyotomies or pyloroplasties, and if patients had emptying trouble they performed Botox injections." — Tim (host_summary) [Ep 1 · 28:49](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- "Adult thoracic surgeons found more problems with reflux and stricture at the esophagogastric anastomosis when they performed pyloroplasty during gastric pull-up." — Tim (host_summary) [Ep 1 · 28:49](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- "Over time, even though vagus nerves are divided during gastric pull-up, the stomach will eventually empty without pyloroplasty." — Tim (host_summary) [Ep 1 · 28:49](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- "When pyloroplasty is not performed during gastric pull-up, there is a lower rate of stricture at the esophagogastric anastomosis, possibly because bile is seen in the stomach on endoscopy indicating the pylorus is functioning." — Tim (clinical) [Ep 1 · 28:49](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- "Some surgeons perform a mucosal-sparing pyloroplasty (essentially a pyloromyotomy closed transversely) rather than full-thickness pyloroplasty." (host_summary) [Ep 1 · 30:04](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1804)
- "Operative intervention for hiatal hernias is indicated in symptomatic patients with type 1 or other paraesophageal hernias." — Tim (host_summary) [Ep 1 · 30:32](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1832)
- "For asymptomatic type 1 (sliding) hiatal hernias, operative intervention is not indicated." (clinical) [Ep 1 · 31:21](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- "For asymptomatic paraesophageal hernias (types 2-4), operative intervention is indicated." (clinical) [Ep 1 · 31:21](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- "In developmentally delayed children who develop small hiatal hernias after fundoplication, if they are asymptomatic, observation is appropriate given the high operative risk." — Tim (clinical) [Ep 1 · 31:21](https://library.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- "The case is a redo fundoplication in a 30 kg child using the 3 mm Percuvance system" (clinical) [Ep 3 · 0:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=0)
- "The Percuvance instrument is inserted by first inserting a needle tip on the shaft, then inserting through a 5 mm trocar placed in the left mid quadrant, then attaching the grasper" (clinical) [Ep 3 · 0:20](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=20)
- "Three Percuvance instruments are used, supplying both liver retraction and stomach manipulation" (clinical) [Ep 3 · 1:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=60)
- "The stomach retractor needle tip is inserted directly through the abdominal wall and then a grasper is attached to retract on the stomach" (clinical) [Ep 3 · 1:15](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=75)
- "The 5 mm effector tips allow for atraumatic manipulation of the stomach in this larger child" (clinical) [Ep 3 · 2:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=120)
- "The previous wrap appears to be intact but is loosened, and there is a small hiatal hernia" (clinical) [Ep 3 · 2:15](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=135)
- "Complete takedown of the wrap and exposure of the left crus is a key maneuver in redo fundoplication" (opinion) [Ep 3 · 2:30](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=150)
- "A two-stitch crural repair was performed using 2-0 Ethibond suture" (clinical) [Ep 3 · 3:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=180)
- "It is extremely important in redo fundoplication to completely take down the previous wrap so that the hiatal defect can be well visualized and repaired appropriately" (opinion) [Ep 3 · 3:15](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=195)
- "The stomach is retracted down to further lengthen the esophagus to ensure there is adequate length" (clinical) [Ep 3 · 3:45](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=225)
- "The wrap is formed going from stomach to the anterior wall of the esophagus, with the top stitch also including the anterior diaphragmatic rim" (clinical) [Ep 3 · 4:00](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=240)
- "Including the anterior diaphragmatic rim in the top stitch helps lock the wrap into the abdomen and hopefully will prevent recurrent herniation" (opinion) [Ep 3 · 4:15](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=255)
- "Three sutures are placed, each incorporating a bite of the stomach, a bite of the esophagus, and a bite of the wrap portion of the stomach" (clinical) [Ep 3 · 4:30](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=270)
- "Removal of the three Percuvance tips took approximately one minute" (clinical) [Ep 3 · 4:55](https://library.globalcastmd.com/watch/percuvance-redo-nissen-11993?t=295)
- "The Coseal Trinity 5mm device functions as both an excellent dissector with tips almost as fine as a Maryland and a vessel sealer." (clinical) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=0)
- "The Trinity device can seal and divide blood vessels up to 7 millimeters in size." (clinical) [Ep 2 · 3:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=180)
- "The Trinity device produces almost no heat spread, which prevents injury to the stomach, spleen, or surrounding organs." (clinical) [Ep 2 · 3:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=180)
- "Care is taken not to carry dissection high into the hiatus to avoid increased risk of hiatal hernia." (clinical) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=90)
- "The anterior vagus nerve must be identified and preserved during retroesophageal dissection." (clinical) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=90)
- "A 2-0 Ethibond suture on RB1 needle is used for crural repair in patients ranging from 2 kg to 100 kg." (clinical) [Ep 2 · 4:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=270)
- "Establishing good length of intraabdominal esophagus is key to developing a good wrap and preventing a slip Nissen." (clinical) [Ep 2 · 4:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=270)
- "The wrap should be tension-free and brought around behind the esophagus." (clinical) [Ep 2 · 5:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=300)
- "A small anterior bite of the esophagus is taken at the 10 and 11 o'clock position during wrap construction." (clinical) [Ep 2 · 5:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=300)
- "Three stitches are used to complete the wrap." (clinical) [Ep 2 · 5:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=330)
- "The wrap is generally under 2 centimeters in length to ensure that an obstructive force is not created." (clinical) [Ep 2 · 5:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=330)
- "Great care is taken to make sure that the wrap is loose and there is no twisting of the esophagus." (clinical) [Ep 2 · 5:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=330)
- "The patient is started on clear liquids immediately after the procedure and discharged the following morning." (clinical) [Ep 2 · 5:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=330)
- "Trocar placement includes 3 millimeter ports in the epigastrium for retraction and a 3 and 5 millimeter port in the left and right hand respectively for ancillary instruments." (clinical) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=0)
- "The surgeon stands between the patient's legs with the cameraman on the surgeon's left." (clinical) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=0)
- "The gastrohepatic ligament is taken down to expose the right crus and create a safe retroesophageal window." (clinical) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=90)
- "The retroesophageal window is developed to eliminate the risk of injury to the esophagus or the posterior wall of the stomach." (clinical) [Ep 2 · 4:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=240)
- "The left crus is slightly cleaned to better allow for crural repair." (clinical) [Ep 2 · 4:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=240)
- "A small amount of peritoneum overlying the upper esophagus is taken to allow for proper placement in the wrap." (clinical) [Ep 2 · 4:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=240)
- "The stomach retractor is used to lengthen the esophagus by pulling downward, ensuring the wrap is above the GE junction." (clinical) [Ep 2 · 5:00](https://library.globalcastmd.com/watch/lap-nissen-trinity-narrated-11931?t=300)

## Changelog
- Sep 25: 3 items added automatically

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