The scope is then inserted into the submucosal space and the space is dissected using a combination of cautery and cutting (Table 7.1). The endoscopic needle or hybrid knife should be routinely used to inject blue dye into the submucosal space. This helps create the submucosal tunnel through hydrodissection and displays blood vessels more clearly to allow for more accurate ligation (Fig. 7.2). If impedance is experienced at the GE junction or a stricture is encountered within the submucosal space, retracting the scope and making the submucosal space larger often facilitates easier dissection going forward (Fig. 7.3). It is important to continue the submucosal dissection at least 3 cm onto the stomach. The presence of palisading vessels provides a clue that one has reached the stomach.

The myotomy of the circular fibers of the esophagus begins 3 cm distal to the mucosotomy (Fig. 7.4). This is often performed by either using the cut or a combination cut-coagulation setting on the energy device. Using coagulation alone for this portion often causes excessive char, which may make visualization and staying anterior to the longitudinal fibers more difficult. An adequate myotomy onto the stomach can be confirmed by visualizing the presence of the pale appearing gastric mucosa upon intraluminal retroflexion of the endoscope. At least 3 cm of pale gastric mucosa should be visualized to ensure an adequate myotomy was performed (Fig. 7.5). Once this is confirmed, the mucosal defect is closed with sequential endoscopic clips (Fig. 7.6) or endoscopic suturing device (Fig. 7.7) depending on the direction of the initial mucosotomy. The patient is then extubated and taken to a post-anesthesia care unit for post-operative monitoring.