- Steep reverse Trendelenberg
- Port placement
- Retract liver with Nathanson
- Open phrenoesophageal membrane
- Excise gastroesophageal fat pad to expose GEJ, identifying and preserving anterior vagal trunk
- Dissect out anterior oesophagus; don’t go posterior.
- Myotomy
- Split longitudinal fibres and divide circular with harmonic scalpel (or scissors)
- Avoid too much electrocautery to prevent going too deep
- Enter submucosal plane, carry proximally 5-6cm from the GEJ and distally 2-3cm
- onto anterior gastric wall.
- Separate muscle edges for 50% of circumference.
- Endoscopy to rule out perforation and show obstruction is cleared
- Fundoplication
- 60% have reflux and positive pH studies without
- Avoid 360 degree because of dysphagia