Initial descriptions of the transoral incisionless fundoplication (TIF) technique involved reduction of any hiatal hernia by gripping the esophagus with the chassis’ tissue invaginator and advancing the device caudally, and then creation of a full-thickness gastrogastric plication at the level of the Z-line (Fig. 2 A). The helical retractor was used to pull full-thickness gastric wall caudally into the tissue mold. The mold apposed the two layers of gastric wall and sandwiched between them the phrenoesophageal membrane, which could be demonstrated in the canine model and observed in human cases [5 (link)]. Subsequently, polypropylene fasteners were deployed over their respective stylets. This created a partially circumferential fundoplication but was limited to gastric tissue, and was dubbed “ELF”—endoluminal fundoplication—and later “TIF.”![]()
2 B). This new technique was dubbed “TIF 2,” with the gastrogastric technique now referred to as “TIF 1” [5 (link)]. The TIF 2 procedure was demonstrated by manometric vector volume analysis to be superior to the TIF 1 technique and similar (in the canine model) to the Nissen fundoplication [5 (link)].
The use of certain device components has evolved with these techniques. The earliest use of the helical retractor was simply to retract tissue caudally. However, the multifunctional helix also may be used as an anchor toward which the tissue mold pushes tissue. The tissue mold can be used as a stop, ensuring that the H-fasteners deploy properly. It can be used to bring tissue into apposition to create an esophagogastric plication. In conjunction with the anchoring effect of the helical screw, the tissue mold can be used to rotate gastric fundic tissue radially around the distal esophagus.
This report of the TIF 2 procedure in humans owes much to the technique developed by Blair Jobe and Stefan Kraemer [5 (link)]. We have altered the technique by deploying the helical retractor at the lesser curve position only once to maximize the rotational effect. The use of the tissue invaginator to fix the device chassis to the esophagus also has been modified. Applying suction before closure of the tissue mold (TIF 1) enabled reduction of any hiatal hernia, whereas our technique of applying suction after closure of the tissue mold allows for both caudal advancement of the esophagus, enabling an intra-abdominal esophagogastric plication, and rotation of the esophagus, providing better visualization of stylet advancement.
The use of certain device components has evolved with these techniques. The earliest use of the helical retractor was simply to retract tissue caudally. However, the multifunctional helix also may be used as an anchor toward which the tissue mold pushes tissue. The tissue mold can be used as a stop, ensuring that the H-fasteners deploy properly. It can be used to bring tissue into apposition to create an esophagogastric plication. In conjunction with the anchoring effect of the helical screw, the tissue mold can be used to rotate gastric fundic tissue radially around the distal esophagus.
This report of the TIF 2 procedure in humans owes much to the technique developed by Blair Jobe and Stefan Kraemer [5 (link)]. We have altered the technique by deploying the helical retractor at the lesser curve position only once to maximize the rotational effect. The use of the tissue invaginator to fix the device chassis to the esophagus also has been modified. Applying suction before closure of the tissue mold (TIF 1) enabled reduction of any hiatal hernia, whereas our technique of applying suction after closure of the tissue mold allows for both caudal advancement of the esophagus, enabling an intra-abdominal esophagogastric plication, and rotation of the esophagus, providing better visualization of stylet advancement.
