Toupet described a partial wrap some years after the complete one described by Nissen. A partial wrap seemed to him to be more physiological than a complete one.

Dissection approaches the hiatal area on its right side, thanks to a liver retractor. A small nasogastric tube is on place. The lesser omentum is widely opened, and the right crus is easily identified. Then the posterior vagal nerve should be the main landmark to find the relief of the left crus. When the fascia of the left crus has been found, a large window toward the splenic area is opened. In fact, because the short gastrosplenic vessels will never been divided in this technique, this step is only focused on the enlargement of a retrocardial window, which will allow the wrap to be not twisted or stretched.

The main feature of the wrap is to be only a translation of the gastric fundus behind and around the esophagus. Then this wrap is fixed onto the right crus by three stitches. Two other rows of three stitches make the wrap encircling the esophagus only on three-fourth of its girth. The final aspect shows an anterior esophagus wall kept free [12–14] (Fig. 12.2).

This partial fundoplication according to Thal was described in the 1970s by an open approach. Then, laparoscopic series were provided, especially by the team of Utrecht. Hiatal dissection allows a mobilization of the distal esophagus until a sufficient part has reached an intra-abdominal position. The hiatus is calibrated by one or two sutures, while a stent is temporarily introduced into the esophagus.

The fundoplication consists in two rows of three stitches between the anterior wall of the fundus and the anterior wall of the esophagus, in two layers. The last one fixes the wrap to the anterior rim of the hiatus and to the right crus.

Many procedures have been described. All are feasible under laparoscopy; all were invented to obviate some pitfalls or imperfect results of the main techniques. Here are summarized some of them which knew popularity.

Jaubert de Beaujeu procedure’s combines a reconstruction of the His angle according to the Lortat-Jacob principle, an anterior fundoplication as described by Thal and Dor, pulling the esophagus down as far as possible and also anchoring it to the crus and diaphragm. There is no need to divide short gastric vessels. Intra-abdominal fixation of the esophagus around the hiatus is the main step of the procedure. Both edges of the pulled down esophagus are sutured to the adjacent crus and the anterior part of the esophagus to the diaphragm. Then, when recreating the Hiss angle, sutures include also the fascia of the left crus. Anterior fundoplication ends the procedure.

Boix-Ochoa procedure gained popularity in the 1980s. Again, the fundamental aim of this procedure was to restore and maintain the length of the infradiaphragmatic segment of the esophagus. After dissection, several stitches are put between the esophagus and the hiatal orifice. The latter is calibrated by one or several stitches. Then the greater curvature of the stomach is mobilized and fixed to the undersurface of the diaphragm, and an anterior fundoplication is performed.

Other techniques were developed by gastroenterologists for adult patients; however, either they need sized devices which are not adapted to children like endoluminal plication or Stretta procedure or their follow-up is too short in order to apply them to young patients, like injectable fluids.

Any pediatric surgeon today received a training for LARS, with a favorite technique which is depending on his/her team of learning. However, trends and scientific studies moved, so that we must be interested to learn different possible procedures. Nissen and Toupet are first; Thal is also mandatory, for instance, in case to end a Heller intervention.

Having said that, our most frequent practice guaranties our best results. Another consideration is a professional trend to be adapted to a new scientific evidence, such as repeated conclusions from large series and among them RCT (randomized controlled trials). Nowadays, these studies are available [14–19] to prove that postoperative dysphagia is reduced after a partial wrap without impair of efficacy regarding the ARS.

Then, the result of LARS in children is supposed to be maintained life lasting, while a redo [20, 21] is acceptable in case of failure and has also to be explained properly before any parent’s decision is made. Thanks to MIS, this possibility is acceptable and rates of failures as well.

There are some advices in order to propose suitable details in case of specific indications which are not depending on the selected procedure.

Huge hiatal hernia makes more cautious and complicated the step of dissection. In addition, more stitches are needed to close the orifice prior to the ARS.

Because a large amount of cases concern NIP, who often have to undergo heavy cares and possibly other surgeries, LARS has to be successfully performed before pulmonary reflux complications make it at risk. First, the hiatus must be reinforced by several stitches. Second, a very large wrap, without possibility of tension or twist, anchored to the right crus, taking in account the gastrostomy implantation, is recommended. The same advice can be applied to children with a previous diaphragmatic hernia.

Many patients are not investigated regarding the esophageal motility because manometric studies are not available everywhere. Even if a Nissen floppy wrap is performed, dysphagia is more often a complication, as proved by multicentric RCTs. This is especially the case for patients cured from an esophageal atresia, and moreover the stomach size makes a difficult total wrap. A posterior partial wrap obviates this problem.

Statistically, a beating vasculonervous pedicle going to the left liver is visible in 15 % of cases. Even if it makes the procedure more demanding, it must be respected.

At the beginning of experience, a bleeding, a perforation, and an abnormal duration of the procedure can induce a conversion to an open approach in order to control it. Although later, these are possible complications to better manage laparoscopically.

Bleeding can occur during the dissection for different reasons. Younger is the child, more fragile is the liver. A suitable choice of the liver retractor, a regular checking of its position must avoid a tear of the liver. Other causes of bleeding are injuries of retrocardial vessels or splenic parenchyma when creating the retrocardial window. The last one is an injury of the inferior diaphragmatic vessels, more often the left one when we release the superior part of the fundus.