While a thoracic approach was popular in the beginning of the antireflux surgery, it evolved to be used only in cases of large hiatal hernias due to the fear that gastric reduction would be more difficult to accomplish through the abdomen; to current abandonment in favor of the abdominal route.

Laparoscopic approach to antireflux surgery started in 1991. Although some initial studies showed an increase in the rate of complications and worse outcomes compared to open operation [20], nowadays, it is common sense that the laparoscopic route is superior.

Although a minimal esophageal/hiatal dissection has been proposed in order to preserve natural antireflux mechanisms [21], most surgeons believe that an extensive esophageal dissection is mandatory in order to obtain 2–4 cm of esophagus without tension below the diaphragm. This manoeuver helps avoiding hernia recurrence and improve GERD control, since a long segment of abdominal esophagus is an efficient antireflux mechanism [22]. It must be in mind that each centimeter of esophagus dissected in the posterior mediastinum leads to a 0.3 centimeters gain in abdominal esophagus length [23].

Vagal trunks and branches must be carefully identified and preserved during dissection of the esophagus [14].

Hiatal closure is a mandatory step during an antireflux operation: (1) it avoids herniation of the wrap through the hiatus and (2) the diaphragm has a synergistic action with the lower esophageal sphincter protecting against sudden increases in intra-abdominal pressure such as during coughing [24]. One of the main causes of failure after antireflux operation is gastric (wrap) herniation through the hiatus that may be attributed to breakdown of the hiatal closure or a faulty repair.

The use of prosthetic material (mesh) for hiatal reinforcement (hiatoplasty) is a controversial topic (Fig. 4.2). It brings the question of the balance between the risk of recurrence and the risk of mesh-related complications (especially esophageal and gastric erosion) [25]. While some surgeons are more liberal in the use of mesh [26], other are more selective [25]. Recent publication of the results of the late follow-up of a large multicenter trial, shows a high index of recurrence even with mesh [27].

A total fundoplication (Nissen) is the procedure of choice for most cases due to lower reflux recurrence and similar postoperative dysphagia, even in individuals with hypotensive peristalsis [28]. A partial fundoplication (Dor, Toupet) are reserved for cases with impaired peristalsis as in achalasia or scleroderma [29, 30].

Some well-established points are fundamental in achieving a good fundoplication [31].

An ideal fundoplication must be tension-free. An extensive dissection of the posterior attachments of the gastric fundus and an ample retroesophageal window are essential for this purpose. Short gastric vessels division may also help attain a floppy fundoplication. Randomized controlled trials did not show advantages when short gastric vessels are divided [32, 33]; however, in this trials a significant number of patients randomized to not divided the vessels were converted to vessel division due to intraoperative judgement of tension in the fundus after wrapping the esophagus. Moreover, some degree of tension is found in more than 50% of the cases when the short gastric vessels are not sectioned [34] justifying routine division of the vessels. An intraluminal bougie is advocate by some to calibrate the fundoplication [35]. Although one trial showed a higher incidence of dysphagia when a bougie is not used [33] (although esophageal perforation occurred due to the bougie), different series do not show advantages [36].

Another key step in this operation is the choice of the right place to create and position the wrap. Thus, gastro esophageal junction should be well identified, with the removal of the fat pad that is frequently located there, to make sure that the gastric fundus is brought around the esophagus not the stomach. Also, the gastric fundus not the gastric body should be used to create the fundoplication. Failure to this principles may lead to a faulty fundoplication.

Finally, the wrap must be short (1.5–2 cm) and floppy. Tight and long fundoplications are not associated to better reflux control but increases the risk for postoperative dysphagia and gas symptoms [37].