 The distance between the E-G junction and the apex of the hiatus is measured after completely releasing the stomach, using an L-shaped instrument, which prevents errors associated with the two-dimensional video image. The upper arm of the L 90 based on the axis of the measurer is placed at the apex of the diaphragm, and the distance between the base of the arm and the clip is measured in centimeters; the measurement is positive if the junction is above and negative if the junction is below the diaphragm. The length of the intra-abdominal portion of the esophagus that is suitable for the performance of a tension-free fundoplication is approximately 2.5 cm. If the E-G junction, with the stomach completely released, is still fixed above or astride the hiatus, the Collis technique is adopted. If the E-G junction is positioned below the hiatus by only 1-1.5 cm, a scenario in which even the application of slight downward traction on the stomach makes it possible to obtain the 2-3 cm of esophagus necessary to perform the fundoplication, its position creates a condition in which the decision of whether to perform a Collis gastroplasty becomes subjective. In such cases, the investigators generally perform the lengthening procedure if reflux symptoms have been present for many years, if the patient is obese, or if the patient is younger than 60 years. To perform the esophagus lengthening procedure, it is necessary to divide at least two short vessels. By turning the operating table toward the right side of the patient, the surgeon may simultaneously operate through the aforementioned 5 standard laparoscopic ports, as well as a left thoracoscopic port through which the instrument used to lengthen the esophagus is inserted. A thoracostomy is performed at the posterior axillary line at the V-VI-VII intercostal spaces, depending on the patients body shape and size. A 12-mm valvular trocar may be used to prevent loss of pneumoperitoneum and to control intra-thoracic pressures. 