Bicorn procedure: Alternative diaphragmatic hernia surgery

The surgical procedure shown schematically

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Regular anatomy of the stomach

Regular anatomy of the stomach

The regular anatomy of the stomach is shown here: the angle of Hiss and the gastric fundus are in their physiological positions.

Diaphragmatic hernia in situ

Diaphragmatic hernia in situ

This shows what a diaphragmatic hernia in situ (in location) looks like in an affected person. It shows the angle between the oesophagus and stomach. More…

Repositioning of the stomach

Repositioning of the stomach

As this figure shows, the stomach is returned to its natural position very gently with special stomach forceps. More…

Exposure of the hernia gap

Exposure of the hernia gap

This figure shows the hernia gap after it has been exposed. For this process, it is of the utmost importance to not injure any surrounding nerves and vessels. Mehr…

Closing the diaphragmatic hernia

Closing the diaphragmatic hernia

The oesophagus with vagus branches is fastened with a suture. This way, the diaphragmatic hernia is completely presented and can be closed precisely. More…

Restoration of the angle of His

Restoration of the angle of His

There, the diaphragm edges, the diaphragm sides, are often too far apart. However, the peritoneum stretched over them will conceal the gap. In this case, a suture between the diaphragm sides in front of the oesophagus is required as well. More…

Complete reconstruction

Complete reconstruction

This figure shows the complete reconstruction. The upper bicorn-shaped share of the stomach is back in its original position. More…

Frequently asked questions about the Bicorn procedure

The scientific basis of laparoscopic hiatoplasty and reconstruction of the gastro-oesophageal transition in the BICORN technique according to C.B. Ablaßmaier

Laparoscopic surgery revolutionised the procedure in 1990. Now it was possible to perform minimally invasive surgery.
Multiple magnification of the surgical area on the screen allows closure of the diaphragmatic hernia under microscopic conditions for the first time.

Fundoplication turned out to be less relevant in the surgery than the precise restoration of the original anatomy.

In 1990, Bernard Dallemagne performed the first laparoscopic surgery according to Nissen in Liège, Belgium.
Dr. Bernd Ablaßmaier learned the procedure from Dallemagne in Liège in 1991 and established it in Munich thereafter.
In next few years, Dr. Ablaßmaier moved to the university hospital Charité, Berlin, where he optimised several laparoscopic surgical procedures on the stomach. Anti-reflux surgery was improved further.

It became more and more apparent that the formation of cuffs was less important than precise restoration of the original anatomy. In the scope of his teaching and research work, he perfected the achalasia and obesity surgeries (gastric banding, gastric bypass).

Extensive experimental studies further developed the entire field of minimally invasive gastric surgery. The world's first complete minimally invasive gastric removal due to gastric cancer was performed by Dr. Ablaßmaier as well (Habilitation thesis Charité Humboldt University in Berlin by Ablaßmaier: Laparoscopic minimally invasive gastrectomy, 1997).
On the foundation of this extensive experience in minimally invasive gastric surgery, anti-reflux surgery was refined as well.

Anti-reflux surgery as performed and developed by Dr. Ablaßmaier looks as follows today:

The scientific basis of laparoscopic hiatoplasty and reconstruction of the gastro-oesophageal transition in the BICORN technique according to C.B. Ablaßmaier

The BICORN procedure according to C.B. Ablaßmaier can be viewed as a further development of the 180° fundoplication according to Dor. It is based on Stelzner's theoretical foundation on a muscle fibre screw system at the terminal oesophagus (Stelzner 1968, 1966). Friedrich Stelzner is a German surgeon, researcher and university lecturer from the field of visceral surgery. Throughout his career, Stelzner has covered matters of functional anatomy and its effect on surgical procedures. His studies revealed the spiral structures of the oesophageal muscles.

  1. Stelzner, F, Lierse, W. „Der angiomuskuläre Dehnverschluß der terminalen Speiseröhre“ Langb Arch: 1968;32:35-64.
  2. Stelzner, F, Lierse, W. „Strukturanalyse des Ösophagus durch das Karzinom“ Thoraxchir: 1966;14:559-562.

The BICORN procedure according to C.B. Ablaßmaier particularly emphasises precise reconstruction of the hiatus and the his angle. In contrast to procedures shaping a cuff, he preserves the gastric fundus in its original crescent shape. This procedure was developed by Ablaßmaier in the course of the last two decades. It is short for BIological COnservative ReconstructioN, i.e. a biological technique hat reconstructs the original form. The BICORN procedure may be regarded as a "physiological" surgery type. Not only is the technique as such superior, but the BICORN method also is our treatment of choice in light of how relevant the surgeon's experience is for the outcome (Broeders 2011, Hüttl 2005, Bammer 2000, Luostarinen 1999, Coelho 1999, Dallemagne 1996).

  1. Bammer T, Pointner R, Hinder R. „Standard technique for laparoscopic Nissen and laparoscopic Toupet fundoplication.“ Acta Chir Austriaca, 2000: 32:1.
  2. Broeders JA, Draaisma WA, Rijnhart-de Jong HG, Smout AJ, van Lanschot JJ, Broeders IA et al. „Impact of surgeon experience on 5-year outcome of laparoscopic Nissen fundoplication.“ Arch Surg, 2011: Mar;146(3):340-6.
  3. Broeders JA, Rijnhart-de Jong HG, Draaisma WA, Bredenoord AJ, Smout AJ et al. „Ten-year outcome of laparoscopic and conventional nissen fundoplication: randomized clinical trial.“ Ann Surg, 2009: Nov;250(5):698-706.
  4. Coelho JC, Wiederkehr JC, Campos AC et al. „Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease.“ J Am Coll Surg, 1999: 189:356–361.
  5. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. „Causes of failures of laparoscopic antireflux operations.“ Surg Endosc, 1996: 10: 305-310.
  6. Hüttl TP, Hohle M, Wichmann MW, Jauch KW, Meyer G. „Techniques and results of laparoscopic antireflux surgery in Germany.“ Surg Endosc, 2005: 19:1579-1587.
  7. Luostarinen M, Virtanen J, Koskinen M et al. „Dysphagia and oesophageal clearance after laparoscopic versus open Nissen fundoplication. A randomized, prospective trial. .“ Scan J Gastroenterol, 2001: 36: 565–571.

Since 1992, the technique has been professionalised and, most of all, optimised in the scope of more than 1000 surgeries.

Dr. med. J.M. Müller at the Charité was Ablaßmaier's teacher, who encouraged him to improve the Dor procedure and supported him in dispensing with the Nissen technique or Toupet technique the laparoscopic procedure, while preferring the Nissen-Rossetti technique and eventually the Dor technique instead. Compared to 360° fundoplication according to Nissen, the partial technique according to Dor forms a procedure a lower adverse-effect profile at similar symptom control (Broeders 2013, Varin 2009, Watson 1999, Patti 1998, Hunter 1996).

  1. Broeders JA, Roks DJ, Ahmed Ali U, Watson DI, Baigrie RJ, Cao Z et al. „Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials.“ Ann Surg, 2013: May;257(5):850-9.
  2. Hunter, JG, L Swanstrom, und JP Waring. „Dysphagia after laparoscopic antireflux surgery. The impact of operative technique.“ Ann Surg, 1996: July;224(1):51-57.
  3. Patti MG, Arcerito M, Feo CV, et al. „An analysis of operations for gastro-oesophageal reflux disease. Identifying the important technical elements.“ Arch Surg, 1998: 133:600-607.
  4. Varin O, Velstra B, De Sutter S, Ceelen W. „Total vs partial fundoplication in the treatment of gastroesophageal reflux disease: a meta-analysis.“ Arch Surg, 2009: Mar;144(3):273-8.
  5. Watson DI, Jamieson GG, Pike GK, Davies N, Richardson M, Devitt PG. „ Prospective randomised double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication.“ Br J Surg, 1999: 86; 123-30.

The role of the surgical procedure in the occurrence of adverse effects is illustrated in the following table. The ratio of adverse effects after partial fundoplication was significantly lower than after Nissen fundoplication.

Technique Gas bloat syndrome with, among other things, gastric emptying disorders, feeling of fullness, meteorism and diarrhoea in % Inability to burp in %
Nissen fundoplication 41 53
Partial anterior fundoplication (vs. Nissen fundoplication) 19 (vs. 28) 17 (vs. 36)

Table: Comparison of the occurrence of classical fundoplication adverse effects (Watson 1999).

The idea of further optimising the successful Dor technique led to thoughts about the development of BICORN technology. It focuses in particular on restoration of a near-physiological antireflux barrier, without applying a gastric cuff, with fixation of the gastric fundus on the left of the oesophagus, as well as reconstruction of the hiatus and his angle. Due to the anatomical left position of the gastric fundus, it is advisable to fix it laterally to the left of the oesophagus.

Stelzner's anatomical findings on an a-polar ascending and descending scissor-like muscle helix system as a prerequisite for an angiomuscular occlusion mechanism at the terminal oesophagus formed the theoretical basis here (Stelzner 1968, 1966). In particular a hiatus hernia causes the oesophagus to "collapse" and therefore shorten, and to lose tension, along with (chronic) opening of the dilatation occlusion (Stelzner 2004).

Stelzner,F, V Mallek, D, Schneider, B. “Stretching esophagopexy on the gastric wall is the best treatment for gastroesophageal reflux disease“ Zentral Chir: 2004;Oct;129(5):345-9.

Repositioning the gastroesophageal transition, the cardia, from the mediastinum back into the abdominal cavity stretches the oesophagus again and increases the "pre-tension" in the oesophagus. The muscles can perform their pumping function again more effectively (Stelzner 2004).

Oesophagopexy, with simple re-tightening of the oesophagus, therefore, needs to be the basis of any effective surgical reflux therapy.

The absence of a gastric cuff is superior since the oesophageal muscle systems are narrowed "on-top" in the sense of an overcorrection of the GEJ, in fundoplication, in addition to re-tensioning the oesophagus and actually restoring the function of the dilatation occlusion this way. Fundoplication therefore does not offer additional anti-reflux protection, but may increase the likelihood of postoperative dysphagia (Stelzner 2004).

Fundoplication therefore is superfluous, and may even be detrimental. The BICORN procedure according to Ablaßmaier, does not repurpose the gastric fundus but leaves it in its original crescent shape. A physiological procedure is enabled this way.

What makes the Bicorn process according to Ablaßmaier special?
Original crescent-shaped shape of the gastric fundus with the Bicorn method

Surgical instruments are inserted into the surgical area through four small skin incisions of 5 millimetres and one of 12 millimetres, guided and controlled via the surgical monitor.

In contrast to treatment methods that use the gastric fundus to form a cuff, this method returns the gastric fundus to its original crescent shape.

(BI-ological CO-nservative ReconstructioN → biological; very careful, preservative; reconstruction; bicorn: "crescent-shaped")

You will find all details about the surgery method on the page treating the Bicorn procedure...

What is the time required for the surgical procedure according to Bicorn?

The preliminary consultation with the anaesthetist takes place at the latest on the day before the surgery. We can perform the necessary preparations for surgery (e.g. blood test, ECG) at this appointment as well.

Minimally invasive reflux surgery involves a three-day stay in the clinic.

  • Day 1: Admission to the clinic and surgery.
  • Day 2: Food increase
  • Day 3: Discharge usually takes place on this day.
How expensive is this treatment?

Private and the statutory health insurances both cover all costs.

What is the likelihood of success of an intervention with the Bicorn method?

I have operated on around 800 patients according to the method described above since 1992. Careful follow-ups were performed on 51 patients who underwent surgery in 2002 as part of a doctoral thesis.

91% of patients in that thesis rated the surgical outcome as very good or good, and 94% of patients would undergo the procedure again to improve their quality of life. More than 90% of the patients see their quality of life returned to normal. The same ratio says that they can fully or mostly dispense with acid blockers after the surgery (dissertation of Dr. Manuel Richter, Humboldt University in Berlin, 2002).

Also read the dissertation of Jessica-M. Rana-Krujatz, 2014, on subjective patient satisfaction after the Bicorn surgery.

What must be observed after discharge?

These are some recommendations for the time after discharge. They are only indicative. Derive your individual stress based on these general directives:


  • Patience
    • Working incapacity: depending on physical stress: 1 to 4 weeks
    • Give your body time to recover
    • Sutures do not need to be removed. The wounds will have been "glued". The glue will come off with skin flakes after 2 to 3 weeks. The tissue beneath the surface of the skin will be closed with dissolving sutures.
    • You can shower starting on the day after the surgery.
      • Do not rub the wounds dry. Only dab them.
      • Bathing is possible after approx. 14 days
    • Lifting of up to 10 kg is permitted
    • Shoulder pain caused by laparoscopy will disappear after about 2 days.
      The abdominal cavity is filled with CO2 gas for an overview with the camera in the abdominal cavity. The gas will be released at the end of the surgery. Small residual amounts of the gas are absorbed by the body and exhaled. By approx. two hours after surgery, no gas will remain in the abdominal cavity. The development of shoulder pain has not yet been clarified. Possible cause could be the stretching of the abdominal cavity during the operation.
  • Sport – permitted:
    • Walking: immediately
    • Average sports: after 6 weeks
    • Intercourse:
      • Moderately
      • Passive: Immediately
      • Active: It can be equated with athletic stress.
    • Extreme sports: after 6 months
  • Eating
    • Please drink only little on the day of surgery.
    • Keep to a light breakfast on the morning of the surgery: Tea, toast, butter, jam, honey
Proper nutrition Avoid as far as possible
Small portions, chew well, eat slowly No flatulent vegetables e.g. cabbage, onions, beans
Apple sauce, yoghurt No breaded dishes
Ice cream without brittle and chocolate sprinklers Rice
Pudding, porridge e.g. semolina porridge, rice pudding Fish -> Be careful with the fishbones
Potatoes and pasta with sauce Keep the amount of carbonated beverages low
Soups, stews and scrambled eggs/td>  
Untoasted toast  
  • Miscellaneous
    • No acid blockers after surgery (a slow reduction of the drug is helpful at Pantoprazole doses above 80 mg)
    • No heparin injections after discharge
    • Gastroscopy after one year is recommended if "Barrett mucous membrane" was diagnosed before the surgery.