This technique has been developed over the last 2 decades with minor revisions to improve outcome [7–9]. The left lobe of the liver is retracted superiorly to expose the gastroesophageal junction through the right upper quadrant port. Although a self-retaining retractor may be used, a babcock retractor with a locking in-line handle can be placed on the diaphragm to expose the hiatus. With the stomach retracted towards the left by an assistant through the left upper quadrant port, the gastrohepatic ligament is divided (Fig. 22.3). The stomach is then retracted to the right and the short gastric vessels are divided either with electrocautery or a sealer device in older children (Fig. 22.4). Short gastric mobilization is necessary to achieve a tension-free wrap. A retro-esophageal window is then created bluntly from the right side with care not to injure the posterior vagus nerve (Fig. 22.5). The right crus should be dissected so that the gastroesophageal junction can be clearly identified and an adequate length of intra-abdominal esophagus is confirmed. A crural repair is then performed in all cases to decrease the risk of hiatal hernia formation post-operatively (Fig. 22.6). The stomach is brought through the retro-esophageal window and a shoeshine maneuver is performed to assure that the stomach is not twisted (Fig. 22.7). The fundoplication wrap is then performed with three sutures (Fig. 22.8). The most superior suture incorporates a small piece of anterior esophagus and right crus to help secure the wrap. The two more inferior sutures incorporate just anterior esophagus. The wrap should be about 2–3 cm and be oriented at the 11 o’clock position. In addition, it is important for the wrap to be above the gastroesophageal junction.

If there is a large defect or recurrent hiatal hernia, the crural repair should be performed with pledgets and horizontal mattress sutures. An orogastric tube is usually sufficient to complete the wrap particularly in smaller infants. However, a bougie may be placed before the fundoplication wrap is performed to avoid creating too tight a wrap around the distal esophagus. Ostlie et al. have published a table of appropriate bougie sizes for infants weighing less than 15 kg [10]. If a gastrostomy is required, the trocar site in the left upper quadrant is used for the button site. A number of techniques may be used to create the gastrostomy .