The right-handed surgeon should stand on the right side of the patient. Make an upper midline laparotomy incision. Extend the incision up and to the left of the xiphoid process for a little additional exposure. Clamp and ligate the small vessels that are frequently encountered in the angle between the xiphoid and costal margin. Do not divide the xiphoid: this adds little to the exposure and may stimulate heterotopic bone formation within the incision. Explore the abdomen and confirm the position of a
nasogastric tube at the cardioesophageal junction. Place a fixed retractor (such as the Omni system) to provide strong cephalad retraction of the left costal margin, placing additional blades to hold the incision open in the midportion. If this type of retractor is not available, a satisfactory alternative is an “upper-hand” type of retractor in the left upper margin of the incision and a Balfour retractor in the middle of the incision. Reverse Trendelenburg position assists as gravity pulls the upper abdominal viscera caudad into the field.

In most cases, adequate exposure can be obtained by placing a liver blade under the left lobe and retracting it upward. If exposure is not sufficient, mobilize the left lobe of the liver by incising the triangular ligament. Pass your left hand around the inferior edge of the left lobe of the liver, grasp it, and pull down. The triangular ligament will be seen as a thin, tough, membranous structure passing along the posterosuperior aspect of the liver. Divide the small vessel at the free edge between hemoclips. Use electrocautery to divide the triangular ligament. As you progress to the right, an anterior and posterior leaf of the triangular ligament will become apparent, with loose areolar tissue between. At this point, continue the dissection cautiously with Metzenbaum scissors until the left lobe of the liver can be folded down to expose the cardioesophageal junction. Place a moist laparotomy pad and Harrington retractor over the left lobe of the liver to hold it out of the way.

The inferior aspect of the diaphragm and the cardioesophageal junction should now be clearly visible. Confirm the location of the esophagus by palpating the nasogastric tube, which is anterior and a little to the left of the aorta at the esophageal hiatus. Incise the peritoneum overlying the cardioesophageal junction to expose the esophagus. Take care to avoid injury to the vagal nerve trunks.