Achalasia Surgery - Mobilizing the Left Hemiliver by Dividing the Triangular Ligament to Expose the Lower Esophagus

A general exploration of the abdomen is undertaken, with particular attention paid to the duodenal wall for evidence of scarring or deformity. The left hemiliver is then mobilized by dividing the triangular ligament to expose the lower esophagus. The peritoneum over the esophagus is divided, and the stomach is retracted downward. The gastrohepatic ligament is divided to allow anterior mobilization of the esophagogastric junction (EGJ). The phrenoesophageal ligaments are divided, and the esophageal fat pad is excised. The surgeon's grasper is then passed posterior to the esophagus to finalize mobilization of the esophagus and to delineate the constricted portion. The myotomy is made by dividing all of the circular and longitudinal (collar-sling) muscular fibers above the area of constriction. The incision is extended 6-8 cm on the esophagus and 1.5-3 cm onto the gastric cardia to reduce outflow resistance. The muscularis should be "undermined" to allow wide separation of esophageal muscles, but care must be taken to avoid making an incision entirely through mucosa.