Position the patient supine with slight reverse Trendelenburg to allow gravity to provide retraction on the abdominal viscera. The primary surgeon should stand to the right of the patient. Make an upper midline laparotomy incision, extending it cephalad to the left of the xiphoid process, if necessary. Explore the abdomen, have an orogastric tube passed, and confirm placement within the stomach. Place a fixed retractor to provide cephalad retraction of the costal margins.

Identify the left lobe of the liver and retract it to expose the hiatus. If this maneuver does not provide adequate visualization of the hiatus, the left lobe may be further mobilized by incising the left triangular ligament (see Figure 51.1). The gastrohepatic ligament is identified. Seek and identify any anomalous hepatic vasculature and preserved it before incising the gastrohepatic ligament. After incising the gastrohepatic ligament, identify the esophagus by palpating the orogastric tube. Incise the peritoneum overlying the right crus to dissect the right crus away from the esophagus. This will allow entrance into the mediastinum for dissection of the hernia sac and reduction of the herniated viscera. General mobilization of the esophagus proceeds as outlined in Chapter 51, Figure 51.2 either at this point or after reduction of the sac (below).

The diaphragm is a dome-shaped muscle separating the thoracic and abdominal cavities. During respiration, the central portion of the diaphragm moves while the peripheral attachments of the diaphragm remain fixed. The diaphragm has three origins: The second and third lumbar vertebrae, the costal cartilage of ribs 7 to 12, and the inner part of the xiphoid process. The fibers of the diaphragm converge to form a trifoliate central aponeurosis named the central tendon. The inferior vena cava (IVC) passes through the central tendon to enter the heart.