with the widespread use of laparoscopy in the 1990 's , many patients with heartburn and sequelae from gastroesophageal reflux disease ( gerd ) are undergoing repair of their hiatal hernias .
although there is a greater than 85% success rate , complications and failures occur following surgery ( table 1 ) .
one of the major concerns during the operative procedure is safe placement of a dilator or bougie .
many times the passage of the bougie is not performed by the operating surgeon but by a surrogate , like the anesthesiologist .
it is ironic that most surgeons are not concerned by the anesthesiologist placing an orogastric tube for intraoperative gastric decompression and rarely is this 18f tube a cause of a complication , like perforation . with this in mind
, a dual tube system was developed to decrease the incidence of esophageal perforation and allow safe dilator placement .
the first portion of the system is a standard 18f single lumen  levine - type tube .
the length is marked to assist placing the tip of the tube through the mouth into the stomach .
it is extended with a screw cap to double the length and allow easy threading of the bougie over the  levine tube .
the second portion of the system is a clear dilator measuring 48f or 58f where the tip is bored out to allow passage of an 18f tube .
it has marks indicating distance from the tip to guide the operator and surgeon while advancing the bougie down the esophagus and into the stomach .
the surgeon using the laparoscope should observe the dilator pass into the stomach as the operator indicates the length of bougie passed .
the surgeon may need to grasp the stomach as the bougie reaches the gastroesophageal junction .
the bougie can be pulled back or readvanced , as needed , during the hiatal hernia repair as sutures are placed or as the wrap is pulled behind the esophagus .
the 18f orogastric tube has a dual purpose  to suction out the stomach and to act as a guide for the dilator to be passed directly into the stomach ( figure 1 ) . at the completion of the surgery
, the 18f orogastric tube may be replaced through the nose for postoperative gastric decompression .
laparoscopic repair of hiatal hernias was introduced at the baptist : hospital laparoscopic surgery center in 1994 . since that time
, 145 patients have had the procedure performed . during the first 3 years of performing these procedures ( 102 patients ) , there were 5 perforations of the esophagus and 3 wraps that were redone for being too tight .
there was difficulty with this system in getting the stiff tapered tip past the oropharynx .
this system was abandoned for a softer , blunt - tipped system much like a 
there was one stomach perforation from an orogastric tube , but it was not related to the dilator system .
this perforation was recognized and repaired at the time of the hiatal hernia repair and caused no postoperative sequelae .
the average age of all patients was 51 years , which did not change over the 4-year period .
operative time has declined to 132 minutes , after initial times began at 210 minutes .
length of hospital stay was 2.3 days for the first 3 years and , during 1997 , had decreased to 1.66 days . since the introduction of the new dilator system , there have been 5 postoperative complications of which 3 were atelectasis , the one recognized gastric perforation noted above , and one patient returned to the or on the same admission to have a heller myotomy following a toupet fundoplication .
intraoperative esophagogastroscopy was performed by one of the operating surgeons or the gastroenterologist who had referred the patient for surgery .
it confirmed proper wrap size and placement , as well as testing the security of the sutures holding the wrap in place .
the stomach was distended with air and submerged in saline during the gastroscopy to look for air bubbling indicating a perforation .
reports in the literature have quoted excellent control of reflux symptoms after laparoscopic nissen fundoplication from 85 to 91% . however , with any surgical operation there are well recognized complications .
there are numerous reports in the literature discussing the benefits justifying laparoscopic fundoplication for the treatment of gerd .
a few of the reports have been examined and the perforation rates and dysphagia rates identified ( table 2 ) .
weerts and dallemagne reported 1 perforation , 2 lacerations of the gastroesophageal junction and 1 wrap disruption in 132 patients .
. reported on 17 perforations in 364 patients of which 5 were due to the passage of the bougie .
one of the first reports in the literature in 1994 was by hinder who noted 3 perforations in the first 198 patients .
swanstrom and pennings discussed safe dissection and had 2 complications from the bougie in 152 procedures . reporting on 300 patients over a 4 year period , hunter et al .
the rate of esophageal perforation is probably higher in those institutions that are not performing this surgery at the same number of cases , much like our data .
it is imperative to take every precaution to perform safe laparoscopic dissection of the gastroesophageal junction .
the ge junction in these patients is at high risk of perforation because of the chronic irritation from reflux juices and the angle of the junction below the crura .
there are very few reported or noted perforations from standard orogastric or nasogastric decompression tubes .
the seldinger technique for placement of catheters is well known to surgeons . with this in mind
, the cook esophageal dilator set has been shown in this limited study to be safe and effective for placing a bougie during laparoscopic repair of hiatal hernias .
 the increased use of laparoscopy for treatment of reflux esophagitis has been associated with a 1 - 8% complication rate . 
 perforation of the esophagus from bougie placement , wrap breakdown or too tight a wrap are some of the complications seen from this surgery . 
 an esophageal dilator system was developed to overcome these problems . 
 thirty patients had an esophageal dilator system used whereby a 48f or 58f dilator was placed over a 18f orogastric tube . 
 intraoperative gastroscopy documented a properly created wrap . 
 there were no esophageal perforations or morbidity associated with the dilator . 
INTRODUCTION
TECHNIQUE
RESULTS
DISCUSSION