Cruroplasty in Antireflux Surgery Geometry Not Just Sutures

This video demonstrates the key principles of laparoscopic cruroplasty (hiatoplasty) in the surgical treatment of gastroesophageal reflux disease and hiatal hernia. Emphasis is placed on achieving adequate mediastinal esophageal mobilization after full mediastinal dissection, including division of the phrenoesophageal ligament and blunt and sharp dissection up to the level of the inferior pulmonary veins, in order to obtain a tension-free intra-abdominal esophagus of at least 2.5–3 cm, which is fundamental to a durable repair.

In a standard posterior hiatoplasty, most patients require 2 to 4 non-absorbable sutures to approximate the right and left crura. Classically, the sutures are placed posterior to the esophagus, often beginning inferiorly and progressing cranially, with a typical spacing of 8–10 mm. Each suture bite should incorporate solid crural muscle rather than fascia alone, as the objective is not strangulation of the hiatus but restoration of its native anatomical contour.

In this video, however, the crural closure is demonstrated using a cranial-to-caudal (top-to-bottom) suturing sequence, reflecting the author’s preferred technique.

Practical guidance is provided on assessing appropriate hiatal tightness, emphasizing functional anatomy rather than stitch count. The role of bougie calibration is discussed, including commonly used sizes (50–56 Fr) and its function as a safeguard against excessive narrowing. For surgeons who prefer not to use a bougie, alternative visual and instrument-based methods for hiatal calibration are also demonstrated.

A key concept highlighted is that postoperative dysphagia is more frequently related to over-tight crural closure than to the fundoplication itself. The hiatus should support the repair without dominating it—achieving a balance that is anatomical, secure, and physiologic.