*3.1.4 Fundus dissection*

The entire fundus should be freed posteriorly from the left crus. In order to properly diagnose a hiatal hernia and ensure that no fundus tissue is left behind, the left crus and gastroesophageal junction must be fully exposed. A gastric fat pad (especially if it is large and complicates the resection) can be resected.

**Tip**: The surgeon pulls the stomach slightly to the right-downward via the left hand, and the first assistant gently performs various maneuvers, such as pulling the fundus up or to the right to provide the best visualization. This is the most efficient maneuver to achieve adequate exposure for the fundus dissection.

**Pitfall:** During this portion of the procedure, care should be taken to avoid excessive traction and bleeding from short gastric and splenic vessels. Possible bleeding in

#### **Figure 7.**

*(a, b) Traction of the fundus (The surgeon pulls the stomach slightly to the right-downward, and the assistant does the active maneuvers).*

this splenic region can be difficult to control, especially in patients with a higher BMI. A sponge can be placed in this area to control the bleeding (**Figure 7**).
