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Page 4 of 5 Herbella et al. Mini-invasive Surg 2019;3:22 I http://dx.doi.org/10.20517/2574-1225.2019.19

A B

Figure 6. Palpator as a pointing device indicates the lowermost point for a cardiomyotomy A and an the identification of an esophageal
leiomyoma (dotted circle) B

The hiatus and the esophagus are initially approached through the right side after opening of the
gastrohepatic ligament. The palpator may be used to retract the right arm of the crus or the esophagus,
allowing the learning surgeon to have both hands free for dissection. Similarly, the esophagus is dissected
from the hiatus circumferentially in a clockwise direction [Figure 4].

CONCLUSION
Operations on the esophagogastric junction in our university are entirely performed by a 4th year resident
under direct supervision of a senior attending that acts as the first assistant in this didactic approach. This
approach was feasible for all cases of Nissen fundoplication or Heller’s myotomy with exposure comparable
to the classic approach [Figure 2]. In some cases of large, steatotic livers, the exposure may be cumbersome.
In these cases, however, the palpator is kept immobile pushing the left lobe of the liver against the
diaphragm above the esophageal hiatus. The advantages of a mobile stick are lost but the operation can be
carried on similarly to the classic approach.

We believe this didactic approach is not necessarily carried by a well-trained team. However, it is a minor
modification of the standard operation that has advantages on surgical training in academic centers.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Herbella FAM, Katayama RC

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.