Laparoscopic surgery of the gastroesophageal junction

Incompetence of the lower esophageal sphincter mechanism leads to gastroeso phageal reflux (GER), which is the most common indication for surgery of th e gastroesophageal junction. Evaluation, diagnosis, and the modern surgical treatment of GER are discussed. Evaluation of patients with severe heartbu rn include upper endoscopy to evaluate the general condition of the esophag us, stomach, and duodenum; an upper gastrointestinal contrast study for a c omplete anatomic view of the esophagus and stomach; esophageal manometry to evaluate the function of the esophagus; 24-hour pH monitoring to determine esophageal acid exposure; and a gastric emptying study selectively to dete rmine the presence of a motility disorder. These studies most often prove t he diagnosis of gastroesophageal reflux, hiatal hernia, Barrett's esophagus , peptic esophageal stricture, paraesophageal hernia, or achalasia. The lap aroscopic approach to treatments for these include Nissen fundoplication, T oupet fundoplication, Collis gastroplasty with fundoplication, modified Hel ler myotomy, esophageal diverticulectomy, and revisional operations. These procedures are described in detail. The results of these operations indicat e that they are safe and effective and should be considered the new gold st andard for correction of gastroesophageal pathology. Laparoscopic surgery h as revolutionized many procedures traditionally performed through a laparot omy. Although they are technically more difficult and require a significant amount of time and practice for the surgeon to become proficient, it is be coming apparent that for functional surgery of the gastroesophageal junctio n laparoscopy is the access of choice.