Hiatal Hernia Repair Research Articles

Bikini-line Hiatal Hernia Repair (BLHHR) During Sleeve Gastrectomy

BackgroundTo preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes.MethodsA prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed.ResultsAmong 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved.ConclusionBLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.Graphical

Safe thoracoscopic repair of recurrent congenital diaphragmatic hernia after initial open abdominal repair.

The optimal surgical approach for recurrent congenital diaphragmatic hernia (CDH) remains controversial. We compared the surgical outcomes of a thoracoscopic approach versus an open abdominal approach for recurrent CDH after initial abdominal open repair. The subjects of this comparative study were patients who underwent open abdominal or thoracoscopic surgery for recurrent CDH following an initial open abdominal repair. Among 166 patients with Bochdalek-type CDH, 15 underwent reoperation for recurrent CDH following an open abdominal repair. Seven patients underwent open abdominal surgery (group O) and eight underwent thoracoscopic surgery (group T). The operative duration was similar for the two groups, with less blood loss (17.2ml/kg vs. 1ml/kg, P = 0.001) and fewer intraoperative complications in the T group (n = 6 vs. n = 0 cases, P = 0.001). There was no significant difference in the number of postoperative complications (n = 1 vs. n = 1, P = 1.0) or in the number of patients with a second CDH recurrence (n = 2 vs. n = 1, P = 0.569) between the two groups. Thoracoscopic surgery is preferable to the open surgical approach for recurrent CDH following an initial abdominal open repair.

Robotic repair of a large chronic traumatic diaphragmatic hernia

Robotic repair of a large chronic traumatic diaphragmatic hernia

Hiatal Hernia Repair: Can We Predict the Need for Mesh?

Introduction: The use of mesh for paraesophageal hernia repair is controversial due to concerns about long-term complications. This study aimed to investigate whether preoperative imaging characteristics of diaphragmatic hernia could predict the need for mesh repair. Methods: The records of all patients who underwent laparoscopic diaphragmatic hernia repair between September 2015 and September 2022 were reviewed. Patients' preoperative computerized tomography (CT) imaging was reviewed and was correlated with mesh repair. Results: A total of 53 patients were included in the study. Volumetric measurements were obtained from preoperative CT scans to assess hiatal defect area (HDA) and hernia sac volume (HSV). Mesh repair was required in 43.4% of cases, all among types II-IV. The mesh repair group had a higher mean hiatal neck height (50.8 ± 16.35 versus 43.22 ± 17.08 mm, P < .032) and higher HSV (708.53 ± 577.6 versus 346.866 ± 321.65 cm3, P < .003). There was also a borderline difference in HDA mean values (23.78 ± 17.22 versus 16.8 ± 10.41 cm2, P < .059). Conclusions: Preoperative HSV on CT scans can be a valuable predictor for the need for mesh repair during hiatal hernia surgery, aiding surgical planning and decision-making. Further research is needed to validate these findings and optimize hernia repair outcomes.

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed. To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD. A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population. Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft). The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs. Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01). Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD. ClinicalTrials.gov Identifier: NCT05069493.

A 20-Year Update on the Practice of Thoracic Surgery in Canada: A Survey of the Canadian Association of Thoracic Surgeons.

This study provides an update to a landmark 2004 report describing demographics, training, and trends in adherence to thoracic surgery practice standards in Canada. An updated questionnaire was administered to all members of the Canadian Association of Thoracic Surgeons via email (n=142, compared to n=68 in 2004). Our report incorporates internal data from Ontario Health and the Canadian Partnership Against Cancer. Forty-eight surgeons completed the survey (male, 70.8%; mean±standard deviation age, 50.3±9.3 years). This represents a 33.8% response rate, compared to 64.7% in 2004. Most surgeons (69%) served a patient population of over 1 million per center; 32%-34% reported an on-call ratio of 1:4-1:5 days, and the average weekly hours worked was 56.4±11.9. Greater access to dedicated geographic units per center (73% in 2021 vs. 53% in 2004) has improved thoracic-associated services and house staff, notably endoscopy units (100% vs. 91%), with 73% of respondents having access to both endobronchial and endoscopic ultrasound. Access to thoracic radiology has also improved, particularly regarding positron emission tomography scanners per center (76.9% vs. 13%). Annual case volumes for lung (255 vs. 128), esophageal (41 vs. 19), and mediastinal resections (30 vs. 13), along with hiatal hernia repair (45 vs. 20), have increased substantially despite reports of operating room availability and radiology as rate-limiting steps. This survey characterizes compliance with current practice standards, addressing the needs of thoracic surgeons across Canada. Over 85% of respondents were aware of the 2004 compliance paper, and 35% had applied for resources and equipment in response.

Pediatric Thoracoscopy: Ten Years Experience in Tertiary Hospital

Purpose: A minimally invasive Thoracoscopic Surgery (TS) offers several options in diagnosis and surgical treatment in pediatric surgery. This study evaluates experience and outcome of thoracoscopic surgery in pediatrics during 10 years period in tertiary hospital. Patients and methods: This retrospective study conducted at King Faisal Hospital and Research Center, Jeddah, Saudi Arabia from 2012 to 2022. Data of 43 patients who underwent TS were enrolled. Data include patient’s demographic characteristics, co-morbidity, diagnosis, type of thoracoscopic procedures, time of intervention, length of hospital stay, post-operative complications. Results: Mean age of patients was 4.99 years. Females were more than males (55.8 vs. 44.2%). Sixteen (37.2%) patients had comorbidities. Thoracoscopic proce- dures were feasible in 43 children and adolescents with chest diseases including lung empyema (20.9%), congenital lobar emphysema (14.0%), interstitial lung disease (14.0%), congenital pulmonary airway malformation (11.6%), mediastinal mass (9.3%), lung metastasis (11.6%), lymphoma (4.7%), chronic inflamma- tions (7.0%), hemothorax (2.3%), bronchogenic cyst (2.3%), pleural effusion (2.3%) and pulmonary sequestration and right diaphragmatic hernia (2.3%). Proce- dures were made mostly for lung biopsy (25.0%), lobectomy (22.7%), decortication (20.9%), mediastinum mass resection (6.8%), lung metastasectomy (6.8%), lymph node biopsy (4.5%), diagnostic (4.6%), cyst excision (4.6%), diaphragmatic hernia repair (2.3%) and thymectomy (2.3%). Duration of hospital stay ranged from 2-180 days. All of the cases had chest drain (100.0%) and some of them required post-operative intubations (30.2%). Conversion rate to open was (4.7%). Complications were pneumothorax (7.0%), bleeding (2.3%) and air leak (2.3%). Conclusions: Thoracoscopic approach is a challenging method for diagnosis and treatment in pediatrics. However, complications were reported as pneumo- thorax, bleeding and air leak. In order to improve results, conversion rates, and the capacity to handle thoracoscopic complications, proper training is crucial.

Laparoscopic repair of recurrent congenital diaphragmatic hernia: A case report

Laparoscopic repair of recurrent congenital diaphragmatic hernia: A case report

S1245 Patient Outcomes Following Transoral Incisionless Fundoplication and Magnetic Sphincter Augmentation with Concomitant Hiatal Hernia Repair

S1245 Patient Outcomes Following Transoral Incisionless Fundoplication and Magnetic Sphincter Augmentation with Concomitant Hiatal Hernia Repair

Laparoscopic hiatal hernia repair for treating patients with massive hiatal hernia and iron-deficiency anaemia

BackgroundMassive hiatal hernias may result in extraoesophageal symptoms, including iron-deficiency anaemia. However, the role played by hiatal hernias in iron-deficiency anaemia is not clearly understood. We examined the prevalence of anaemia in patients with massive hiatal hernias and the frequency of anaemia resolution after laparoscopic hiatal hernia repair at long term follow-up.MethodsPatients who underwent laparoscopic hiatal hernia repair from June 2008 to June 2019 were enrolled in this study. We collected the patients’ demographic and clinical data from their medical records, and compared the pre-surgical and post-surgical findings (at 1 week and 3 months post-surgery). All patients with adequate documentation underwent post-surgical follow-up to evaluate improvements in clinical symptoms and signs.ResultsA total of 126 patients with massive hiatal hernias underwent laparoscopic hiatal hernia repair. Of these, 35 (27.8%) had iron-deficiency anaemia. Anaemia was resolution in all the patients and they had significantly reduced GERD-Q scores at 3 months postoperatively (P<0.01) .The mean follow-up period was 60 months. Iron-deficiency anaemia resolution after hiatal hernia repair was achieved in 93.9% of the patients.ConclusionAnaemia is common in patients with massive hiatal hernias, and most of our patients were symptomatic because of their anaemia. Moreover, in patients with massive hiatal hernias, iron-deficiency anaemia resolution is likely after laparoscopic hiatal hernia repair.

Technical Considerations and Approach to Redo Foregut Surgery.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redohiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissectionto free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center

BackgroundLaparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. MethodsAfter IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50–75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. ResultsA total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6±9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8±3.2 vs 1.4±0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4–8.4, p < 0.001). At a mean follow-up time of 43.1±25.0 and 43.5±21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5±10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. ConclusionsHHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis.

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence. A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time. Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates. Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

Feasibility and Outcomes of Same-Day Surgery in Primary and Reoperative Laparoscopic Hiatal Hernia Repair

ObjectiveTo assess the feasibility and outcomes of same-day surgery in primary and reoperative laparoscopic hiatal hernia repairs. MethodsSame-day surgery was planned in elective procedures with ASA II–IV. An Enhanced Recovery After Surgery (ERAS) protocol was implemented to achieve same-day surgery, and opioid-based anesthesia was replaced by opioid-free anesthesia. Outcomes were assessed by length of stay, transition from same-day surgery to observation or inpatient, and postoperative emergency department visits/readmissions. The predictors of same-day surgery were assessed. Values are presented as median (interquartile range). ResultsFrom 04/13/2017 to 09/29/2022, there were 518 laparoscopic hiatal hernia repairs in 491 patients, 428/518 (82.6%) were primary, and 90/518 (17.4%) were reoperative. In the primary group, 314/428 (73.4%) were planned as same-day surgery and 246/314 (78.3%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 77/314 (24.5%) vs. same-day surgery with opioid-free anesthesia protocol in 169/314 (53.8%), p < 0.001, 41/246 (16.7%) same-day surgery primary procedures had emergency department visit post-discharge, and 26/246 (10.6%) were readmitted. In the reoperative group, 51/90 (56.7%) were planned as same-day surgery, and 27/51 (52.9%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 2/51 (3.9%) vs. same-day surgery with opioid-free anesthesia protocol in 25/51 (49.0%), p < 0.001, 3/27 (11.1%) same-day surgery reoperative procedures had emergency department visit post-discharge, and 3/27 (11.1%) were readmitted. Opioid-free anesthesia protocol was the positive predictor of same-day surgery compared to opioid-based anesthesia protocol (OR 7.44 [95% CI: 2.94, 18.83]), p < 0.001. Negative predictors were ASA III compared to II (OR 0.52 [95% CI: 0.28, 0.94]), p = 0.031, and duration of operation (OR 0.98 [0.97, 0.99]) p < 0.001. ConclusionLaparoscopic hiatal hernia repair can be performed as same-day surgery in the majority of primary and reoperative procedures with good outcomes and low postoperative emergency department visits and readmissions. The odds of same-day surgery are higher with opioid-free anesthesia, lower ASA, and shorter operative time.

Topic: Esophagus Benign-GERD, Achalasia, Motility Abstract ID: 36 Pleurotomies During Minimally Invasive Anti-Reflux and Hiatal Hernia Repair are Not Associated With Higher Rates of Complications

Topic: Esophagus Benign-GERD, Achalasia, Motility Abstract ID: 36 Pleurotomies During Minimally Invasive Anti-Reflux and Hiatal Hernia Repair are Not Associated With Higher Rates of Complications

Topic: Esophagus Benign-GERD, Achalasia, MotilityAbstract ID: 63The Use of Coated Poly-4-hydroxybutyrate (Phasix™ ST) Mesh in Hiatal Hernia Repair: Our Institutional Experience and Review of the Literature

Topic: Esophagus Benign-GERD, Achalasia, MotilityAbstract ID: 63The Use of Coated Poly-4-hydroxybutyrate (Phasix™ ST) Mesh in Hiatal Hernia Repair: Our Institutional Experience and Review of the Literature

194: Low Surgical Complication Rate with Early Repair of Congenital Diaphragmatic Hernia on Extracorporeal Life Support Using a Standardized Protocol and Bivalirudin for Anticoagulation

194: Low Surgical Complication Rate with Early Repair of Congenital Diaphragmatic Hernia on Extracorporeal Life Support Using a Standardized Protocol and Bivalirudin for Anticoagulation

Pre-operative bariatric patient characteristics driving hiatal hernia repair decision by operating surgeons

Pre-operative bariatric patient characteristics driving hiatal hernia repair decision by operating surgeons

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PurposeLaparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.MethodsRetrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.Results862 giant PEH repairs met selection criteria. There was an increasing proportion of “composite repair” after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study’s end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien–Dindo grade ≥ III complications including two perioperative deaths (0.2%).ConclusionHernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach.

412. INTRAOPERATIVE APPLICATION OF ENDOFLIP FOR THE REPAIR OF HIATUS HERNIA AND FUNDOPLICATION

Abstract https://drive.google.com/file/d/1N3wVZ2UvO3eGBScjHMwtcJiCqfU0wUp1/view Background There is no objective measurement during repair of hiatus hernia and fundoplication intraoperatively. Whether the patient needs Nissen, Toupet or other fundoplication requires individual consideration. If the wrap repaired too tight, patient will develop dysphagia after surgery. If the wrap fold too loose, then the patient may experinced persistent reflux symptoms. This video demonstrate the application of EndoFlip intraoperatively to objectively measure the distensibility of the lower esophageal sphincter. Method Patient underwent laparoscopic hiatus hernia and fundoplication after symptoms assessment and confirmation of diagnosis. Intraoperatively, EndFlip probe was inserted and distensibility were measured as pre-dissection, post abdominal resection, post crural repair and after fundoplication. Tightness of fundoplication is adjusted aming at distenisbiliary index ranged 2–4. Results This study demonstrate the intraoperative aspproach for using EndoFlip as the tool to adjust the appropriate tightness on creating the wrap. Fpr this particular patient, before crus dissection, the distensibility index (DI) was 4.5, after crural dissection, DI was 5.5. After crural repair and Toupet fundoplication, the DI was 2.5. Post-operatively, patient had all the proton pump inhibitor stopped and enjoying good quality of life. Conclusion Objective intraoperative measurement during fundoplication is now available. Appropriate tightness of the wrap can be adjusted to avoidf post operative dysphagia or persistent reflus.