A 42-year-old female patient with a body mass index of 36 kg/m2 presented to our clinic with obesity and symptomatic GERD. She had been using proton pump inhibitor (PPI) regularly for 1 year. Patient's preoperative GERD-HQRL (Heartburn score 0-30) was 25. The patient, also, had insulin resistance, grade 2 hepatosteatosis and dyslipidemia as comorbidities due to obesity. Preoperative endoscopy showed hiatal hernia but no esophagitis. One week after discontinuation of PPI, the patient underwent ambulatory pH study and GERD was confirmed. The patient was scheduled to have laparoscopic hiatal hernia repair plus combined partial posterior fundoplication and sleeve gastrectomy (Fig. 1). She was given thorough information about the operation and informed consent was obtained.
The 12 mm optic trocar (Endopeth Xcel ) was entered into the abdomen under direct vision from the left supcostal area and insufflated with 12 mmHg CO2. SG was performed with 5 trocars. Lesser suck was opened and greator curvature was disected using harmonic scalpel. The stomach was completely released. Hiatus dissection was performed. Hiatal hernia was repaired with 2.0 etibond suture. Then, gastric fundus was passed behind the esophagus and posterior fundoplication was performed (Fig. 2). SG was completed using Endo GIA  60 mm Tri-stapler (4 purple and 1 brown cartridge) starting from 2 cm distance to the pylorus using 36 French bougie. After the SG was completed (Fig. 3), the stapler line was inverted at the top with 3.0 V-Loc  and the next 3-4 cm sutures were passed through the esophagus and the left side of the fundoplication was created (Fig. 4). Then the entire stapler line was oversewed. At the last stage, gastric sleeve was fixed to the omentum at 2 points below the incisura to prevent twist. The operation took 110 min (see Video, Supplemental Digital Content, which demonstrates combined posterior fundoplication with SG).
The patient recovered well and discharged home on the 3rd postoperative day. She stopped using PPI in the early postoperative period and her reflux symptoms disappeared completely. The patient lost 20 kg in the 3rd month (%40 excess weight loss) and underwent controlled ambulatory pH moniterization and no reflux was detected.