The esophagogastric fatpad is elevated and carefully dissected off of the area of the esophagogastric junction, taking care to identify and preserve the anterior vagus nerve (Fig. 11.2). The ultrasonic coagulator is an ideal instrument for this purpose, as there are frequently small vessels in this area which can bleed and obscure the field. At this point some surgeons will prefer to have a lighted esophageal dilator placed transorally (which is ideally done by the anesthesiologist as long as they are experienced and comfortable with the procedure) which can serve as a sort of “platform” for the performance of the myotomy itself. A point on the anterior gastric cardia approximately 2–2.5 cm to the left of the lesser curvature and 3 cm distal to the esophagogastric junction is chosen to start the myotomy. This is typically begun by scoring the serosa with the electrocautery hook for a distance of at least 1 cm up towards the EGJ, and then carefully dividing the muscle fibers one layer at a time until the submucosa is reached (Fig. 11.3). The submucosa is identifiable as a smooth surface that has a texture distinctly different than the muscularis. The muscle fibers can be disrupted using elevation with the hook and employing cautery only very sparingly. Hooking large bundles of fibers at once should be avoided. Bleeding on the surface of the submucosa can usually be very easily controlled by the gentle application of pressure with a blunt grasper. Notably, this part of the myotomy is the most difficult, because of both the thickness of the muscle in this region and the organization of the “clasp and sling” fibers that make up the gastric component of the LES, which is organized much differently than the more simple outer longitudinal and inner circular muscular layers of the esophageal body encountered in performing the proximal myotomy.

Once the initial area of the distal myotomy is established, blunt graspers are used to grasp either side of the muscularis on the myotomy edge with the assistant grasping the left side of the myotomy and the primary surgeon grasping the right, providing gentle traction which allows the myotomy to continue in a cephalad direction (Fig. 11.4). Alternatively, a babcock grasper can be used with jaws open to stretch the myotomy area laterally to achieve a similar effect. As the myotomy is carried underneath the epigastric fatpad and proximally past the EGJ, it becomes notably easier to bluntly divide the muscularis, particularly the longitudinal fibers, which become more distinct from the underlying circular fibers. Ultimately the myotomy should be continued proximally until the length above the EGJ is 6–8 cm with the esophagus not under tension. This can be measured directly by inserting a sterile measuring stick and holding it in place alongside the myotomy, or by introducing a pre-measured length of suture (Fig. 11.5).

At this point in the procedure, many surgeons will perform an upper endoscopy in order to evaluate the adequacy of the relief of the high-pressure zone of the LES. Observation that the area of the esophagogastric junction is widely patent and easily permits passage of the endoscope is a relatively easy method to determine the success of the procedure intraoperatively. In addition, this permits the visualization of any small areas of perforation that may have occurred during the myotomy, in the same way that the “leak test” is used after an anastomosis is performed in rectal surgery. The use of intraoperative esophageal manometry has been described, with the stated advantages being the ability to identify relatively small specific points of remaining muscle fibers representing a residual high-pressure zone, as well as helping to guide length of the myotomy [11], however this is relatively cumbersome to perform.

Currently there is increasing interest in measuring the distensibility of the high-pressure zone during myotomy as a way to evaluate the success of the procedure intraoperatively. The functional luminal imaging probe (FLIP), using the principle of impedance planimetry to measure the cross-sectional area at several points along the myotomy in relation to pressure, generates a distensibility index expressed in mm²/mmHg. Teitelbaum and colleagues have found that a distensibility index in the range of 4.5–8.5 mm²/mmHg correlates with optimal symptom outcomes [12]. This technology is not widely available in clinical practice at the time of this writing, however, thus it remains to be seen whether or not the distensibility index will become a standard method for intraoperative assessment.

With the myotomy complete, the dilator, if used, can now be removed. To begin the Toupet fundoplication, the posterior fundus is passed through the retroesophageal window to the right side of the myotomy and its superior aspect can be fixed to the base of the right crus with a 2-0 silk or braided nylon to secure the fundus in this position. Next, a suture is placed between the superior aspect of the fundus on the right, the anterior right crus, and the right edge of the myotomy. This is followed by two additional sutures between the fundus and the right myotomy edge progressively more distally. These three sutures are repeated in an identical manner on the left side of the myotomy, adjoining the anteromedial aspect of the fundus to the cut muscularis edge (Fig. 11.6). The area is then inspected for bleeding, hemostasis is achieved as needed, the liver retractor is removed, and the port sites are all closed.