LNF is generally performed in the supine position with the legs extended and abducted 30 to 60 degrees so that the surgeon may operate between the legs. Low lithotomy is a less desirable position as peroneal nerve injury, deep venous thrombosis, and patient movement while in reverse Trendelenburg position is more frequent. Some surgeons prefer the patient in the supine position, operating from either the left or the right side. This setup, however, results in poor ergonomics with resultant chronic shoulder injuries in the surgeon and the need to address the hiatus obliquely. Clearly, optimal positioning favors a split-leg position. The assistant standing to the left of the patient holds the camera with the left hand and assists with the right hand. The monitor is placed over the patients head ideally fixed on a ceiling-mounted boom (Fig. 16.1).

LNF is performed with a five-port technique. The operation begins by insufflating the abdomen with a Veress needle placed above the umbilicus. After obtaining pneumoperitoneum, an 11-mm trocar is placed 15 cm below the costosternal junction slightly to the left of the midline. By placing the port to the left of midline, and obliquely entering the abdomen—aiming toward the esophageal hiatus—the surgeon minimizes the risk of port-site hernia, stays out of the fatty ligamentum teres, stays further away from the left lobe of the liver, and more accurately aligns the laparoscope with the trajectory of the esophagus (right to left) as it traverses the diaphragm. A 45-degree laparoscope is introduced and a brief abdominal survey is performed. All other trocars are placed under direct vision and all sites are infiltrated with local anesthesia before an incision is made. The second 11 mm trocar is introduced along the left costal margin 12 cm from the base of the sternum. The 11 mm trocar facilitates the passage of suture and is useful for the placement of endoscopic clips when necessary. The third trocar placed is 5 mm, generally located 8 cm farther down the left costal margin than the second trocar but not further lateral than the anterior axillary line. A Nathanson liver retractor is introduced through the track of a cutting 5 mm port that has been placed and removed just inferior and left of xiphoid. The liver retractor is connected to a mechanical arm fixed to the right side of the operating table. The optimal position of the liver retractor allows access to the anterior arch of the hiatus as well as thoroughly defining the right crus of the diaphragm. The patient is then placed in steep reverse Trendelenburg position. The fifth trocar is used for the surgeon’s left hand and is placed along the right costal margin just inferior to the edge of the retracted left lobe of the liver. The point at which this trocar is placed is determined by internal, not external, anatomy, and therefore is variable in its
superficial projection. It is generally desirable to have this trocar as high and as wide as possible without going into the left lobe of the liver or achieving placement to the right side of the falciform ligament.

Dissection commences by the assistant grasping the epiphrenic fat pad and retracting inferiorly and slightly toward the patient’s left. This reduces any hiatal hernia and places the phreno esophageal membrane on tension. Next, the surgeon exposes the right crus of the diaphragm by opening the gastro hepatic ligament above and below the hepatic branch of the vagus (Fig. 16.2). While it is desirable to preserve the hepatic branch of the vagus, many surgeons routinely divide it to obtain better access to the right crus. A blunt atraumatic grasper is placed beneath the phrenoesophageal ligament to establish the plane between the esophagus and the diaphragm. This layer is divided with ultrasonic energy (Fig. 16.3). The dissection proceeds around the arch of the hiatus and down the left pillar of the diaphragm as low as is easily visualized. Access to the mediastinum is obtained by placing two blunt graspers (closed) between the esophagus and the right crus of the diaphragm, and then spreading horizontally. This is repeated on the left side of the esophagus. The anterior vagus nerve is generally affixed to the esophagus, and the posterior vagus nerve is not visible at this time. Dissection down the right crus of the diaphragm continues until the surgeon reaches its base where the left crus is visualized emerging from posterior to the esophagus. This completes the preliminary phase of the crural dissection.

The next phase of dissection includes the division of the short gastric arteries, and posterior mobilization of the stomach. The light cord of the laparoscope is rotated 30 degrees counterclockwise (11 o’clock position), and the surgeon grasps the greater curvature of the stomach at the level of the inferior pole of the spleen. The assistant grabs the greater omentum adjacent to the greater curvature of the stomach. The surgeon retracts the stomach to the patient’s right and posteriorly while the assistant elevates the omentum anteriorly and to the patients left. The ultrasonic shears are introduced and entry to the lesser sac is gained by incising the greater omentum adjacent to the greater curvature of the stomach (Fig. 16.4). Several applications of the harmonic scalpel may be necessary to gain access to the lesser sac in heavier patients. It is important that the short gastric vessels are visualized and completely occluded with the ultrasonic shears before the application of energy. Incomplete division of short gastric vessels results in troublesome bleeding. As the dissection moves cephalad, the surgeon keeps moving the retraction point higher along the greater curvature, generally placing one jaw of the atraumatic grasper on the anterior wall of the stomach and one jaw on the posterior aspect of the stomach. The assistant places one jaw of their grasper in the lesser sac, and one jaw in the greater sac to optimally retract the greater omentum.