Surgery 1 (Reflux)

haem_19a_n.jpg to haem_19c_n.jpg: Surgical steps in Nissen's fundoplication (M. Bettex). Laparotomy by a longitudinal incision with view of the stomach, distal esophagus and esophageal hiatus of the diaphragm. haem_19a_n.jpg: The cranial part of the hepatogastric ligament (< >) has been divided, and the peritoneal fold of the esophageal hiatus has been incised circularly. The muscles of the diaphragm and the distal esophagus with both branches of the vagus nerve are now visible. haem_19b_n.jpg: The distal esophagus is pulled down with a string, and the right part of the mobilized fundus is displaced behind the abdominal esophagus to the other side. The sutures to form a sleeve of the fundus are in place. haem_19c_n.jpg: The first row of sutures are tied. In children a second layer of sutures is added. Not visible is the reduction of the esophageal hiatus by sutures near the posterior circumference of the esophagus, and a temporary insertion of a thick gastric tube to avoid a too narrow sleeve of fundus.