Position the patient supine, with the head turned slightly to the right and the neck slightly extended by a roll under the shoulders (Fig. 34.1A). In addition to the usual monitoring devices, place an indwelling arterial line so that blood pressure can accurately be measured on a beat-to-beat basis. Compression on the heart and vena cava during the mediastinal dissection may cause hemodynamic compromise, and accurate blood pressure monitoring and communication between the surgeon and the anesthesiologist are crucial during this operation.

Begin with an upper midline incision and thorough abdominal exploration, including palpation of liver and regional nodes, to confirm that resection is appropriate. Take down the triangular ligament of the liver and fold it to the right, placing a padded retractor over it (Fig. 34.1B) to provide wide exposure of the gastroesophageal hiatus and distal esophagus.

Mobilize the stomach as described in Chapter 30, taking care to preserve the vascular arcades along the lesser and greater curvature.

Next, incise the peritoneum overlying the esophageal hiatus and divide the phrenoesophageal membrane. Encircle the distal esophagus with a Penrose drain (Fig. 34.2) and place gentle downward traction on it. Place a heart-shaped retractor on the esophageal hiatus and elevate it, providing direct exposure into the lower mediastinum. Enter the mediastinum, gently displacing the pleura to each side of the esophagus and taking care not to enter the pleura. Progress upward, gently assessing the mobility of the esophagus and circumferentially mobilizing it by sequentially dividing fibrous attachments and small vessels with electrocautery under direct vision. Take periesophageal soft tissues with this dissection and slowly proceed to the level of the carina.

Place a pack in the mediastinum. Perform a wide Kocher maneuver (if not already done) and a pyloromyotomy. If desired, a feeding jejunostomy can be done at this stage to complete the abdominal phase of the operation.