The lower esophagus is
mobilized as proximally as possible. Six to eight centimeters should
visualized above the GE Junction. Another six centimeters should be
visualized on the anterior aspect of the stomach.
The vagus nerves are exposed and
retracted away from the site of the myotomy.
The myotomy is started by clearing the anterior gastric wall of all fatty coverage. This is
usually done with
the ULTRASHEARS Instrument™ or the Harmonic Scalpel™. The myotomy is
initiated immediately above the gastro-esophageal junction first using an atraumatic grasper and continuing it with the electro-cautery
- at low coagulating power - 20).
First, the longitudinal muscular layers
are identified using an atraumatic grasper. Then, the circular layers are identified
and transected using the electro-cautery. This dissection should be slow and
meticulous. The circular fibers should be carefully elevated away from the
esophageal mucosa, then transected, only a few at a time. The mucosa will
start bulging through the myotomy site, intact. It is essential NOT to
manipulate the esophageal mucosa with any instrument.