To aid in the exposure an incision is made in the anterior portion of the esophageal hiatus, ligating the left phrenic vessels, this incision is continued to the pericardium. Deep hand held retractors are placed into the esophageal hiatus and retracted upward and laterally. Because of hemodynamic compromise, this can only be performed at brief intervals but should give exposure up to the level of the carina. Any major vessels are ligated with clips. Wide exposure, even pleura to pleura is achieved.
Further dissection is continued with electrocautery.
Once the stomach is completely mobilized, the gastric outlet procedure is performed usually by a pyloriplasty but a pylorimyotomy and a pylormyomectomy can also be performed. The neck dissection is then performed. An oblique incision is made following the course the anterior belly of the sternal colloidal mastoid muscle down to the sternal notch. The omohyoid muscle is exposed and transected. Deep self-retaining retractors are not used.