Beach chair, split-legged position with foot-boards and adequate padding to prevent sliding during steep reverse Trendelenburg. Surgeon between legs, assistant to left.
Access/mobilise oesophagus
Gastrohepatic ligament opened, and identification of right crural arch and phreno-oesophageal ligament. Latter is incised at 10 o'clock along crural arc and extended clockwise over anterior aspect of oesophagus to left of crural arch. Upper fundus mobilised.
Identify and protect anterior vagal trunk
Myotomy
Saline + 0.5% adrenaline injected into wall of distal oesophagus, GOJ, cardia of stomach - elevates muscular wall and prevents bleeding during dissection
Start 2cm above GOJ - sharp dissection through muscularis until submucosa is seen.
Can use energy device or hook.
From GOJ, go 6cm proximal and 3cm distal.
Critical aspect is transition from distal oesophagus to GOJ - muscular wall is very thin
Will be able to see the oblique fibres at the collar of Helvetius to determine the transition point
Endoscopy - confirm integrity of mucosa. Underwater seal test
