Fundoplication is the most commonly performed antireux procedure. The role of preoperative manometric evaluation of the esophagus prior to fundoplication is debated. Amongst the possible side-effects of fundoplication are included dyspha­gia and gas bloat syndrome, occurring in approximately 5–8% [76–79] and up to 40% [80] respectively of post fundoplication patients. It has been postulated that preoperative manometric investigation of the esophagus will predict postoperative side effects, particularly postoperative dysphagia. It has also been thought that the “tailoring” of the extent of the fundoplication, whether 90°, 360° or an intermediate extent, would achieve superior postoperative quality-of-life and patient satisfaction. A systematic review provides evidence that this is not the case, and an operation tailored to the manometric measurements of esophageal motility is unwarranted [8]. Nonetheless, many centers do perform preoperative manometry. This is often justi­ed as pre-emptive management of possible postoperative problems. For the post­operative patients who presents with dysphagia (again, averaging 5–8% of all postoperative patients, but much higher in the immediate postoperative period), knowledge of esophageal motility may help guide management. Moreover, certain motility disorders can mimic GERD by demonstrating the same symptomatology. For example, achalasia cardia can present with substernal burning, regurgitation and elevated distal esophageal acid exposure, but in this case the etiology is not due to incompetency of the antireux mechanism. Antireux surgery in such patients would result in a very poor outcome, and hence preoperative manometry will be helpful in such patients. Other preoperative tests have been examined, such as nuclear medicine gastric emptying studies [81], but there are no data to support a correlation between their results and postoperative outcomes. Gastric emptying studies may be important however in patients who require reoperation, as it may provide indirect evidence for vagal nerve injury during the original surgery [8].

anatomical landmarks, that is the diaphragmatic impressions, are often difcult to appreciate particularly in the presence of wide separation of the crura [89]. Therefore, an appreciation of the gastroesophageal junction being above the dia­phragm is often missed. Evaluation of gastric viability is particularly important among patients undergoing emergency surgery for incarcerated hernias.

• Hiatal hernia treatment overlaps with that of the treatment of GERD.GERD is associated with many smaller Type I hiatal hernias; therapy is directed towards treatment of the GERD symptoms rather than the hernia per se. For larger hiatal hernias, often termed paraesophageal hernias, heartburn and regurgitation are only two of a common constellation of symptoms. Indications for surgery include treatment of these reux symptoms but also of obstructive symptoms and to prevent emergent presentations. Preoperative assessment is directed to determining the presence of the hia­tal hernia, conrming it as the cause of the patient’s symptoms and assess­ing tness for surgery. Where large asympatomatic hernias exist, particulary in the elderly, optimal management is less certain and controversy exists about whether suergery is indicated solely to prevent future complications.