An upper midline laparotomy incision extending from just above the xiphoid process to the level of the umbilicus provides adequate exposure of the upper abdominal viscera and the omentum. In patients with central obesity, a bilateral subcostal incision with the division of the bilateral rectus abdominis muscles is an excellent alternative of exposing the upper abdomen to avoid subsequent risk of ventral incisional hernia. The blades of the Thompson retractor are placed in bilateral subcostal regions to aid the exposure of the diaphragm and the GEJ. To avoid tearing the liver capsule from excessive retractor traction, the falciform ligament may be divided to the level of the diaphragmatic attachments.

The left lobe of the liver overlying the GEJ is retracted anteriorly. Mobilization of the triangular ligament is also an option but is rarely necessary. The pars flaccida is opened, exposing the caudate lobe of the liver and the right diaphragmatic crus within the lesser sac. Then, the phreno-esophageal ligament overlying the diaphragmatic crus is incised and the crus is dissected free from the GEJ. If involved with carcinoma, a part of the crus is resected en bloc with the operative specimen to ensure negative radial margins. A penrose drain is passed around the GEJ to aid with manipulation of the esophagus and further dissection proceeds in the superior and lateral periaortic planes and along the pleural surfaces laterally reaching up into the mediastinum. This maneuver facilitates intrathoracic esophageal mobilization; however, care must be taken not to inadvertently injure or partially divide the inferior pulmonary veins on either side.

The transverse colon is lifted out of the body cavity and retracted inferiorly as the omentum is retracted superiorly. The avascular plane between the omentum and colon is opened while carefully avoiding injury to the colon, mesocolon, omentum, and greater curvature blood supply (i.e., the right gastro-epiploic vessels). The omentum is fully mobilized off the transverse colon and mesocolon after entering the lesser sac to the level of the gastroduodenal artery. Care is taken to preserve the entire course of the right gastro-epiploic artery during omental mobilization by careful palpation and/or visualization of this artery. The omental pedicle flap, based on 2–3 perforating omental arterial branches off the right gastro-epiploic artery, is created along the left side of the greater curvature (Fig. 1.2). Gastric mobilization along the greater curvature is completed with the division of the short gastric arteries staying relatively close to the stomach to avoid inadvertent splenic injury.

With the aid of a nasogastric tube in the stomach stretching along the greater curvature, the stomach is elevated to approach the celiac axis and left gastric artery from the lesser sac in the dissection plane created above the mesocolon. The peritoneum overlying the superior edge of the pancreas is incised to reveal the common hepatic and splenic arteries. The tissues anterior and cranial to the common hepatic and splenic arteries is included in the lymph node dissection and lymph node tissues along the left gastric artery is dissected and swept anteriorly with the specimen. The left gastric vein and artery are then divided at their origin (doubly ligated or stapled) after ensuring a good palpable pulse in both splenic and common hepatic arteries. The boundaries of dissection from right to left are the porta hepatis/vena cava to the splenic hilum, respectively; and periaortic tissues from the celiac artery inferiorly up to the extent of the mediastinal resection (Fig. 1.3). Clips should be placed on the larger lymphatics in the area of the porta hepatis to avoid chylous ascites.

Controversy surrounds this portion of the procedure [3]. Some experts leave the pylorus completely intact, whereas others favor pyloromyotomy, botox injection, selective balloon dilation postoperatively, or formal pyloroplasty. Emptying of the gastric conduit through the pylorus may be related to the width of the conduit, however conclusive evidence is lacking. Our preference has been to perform either pyloromytomy or pyloroplasty.

The pylorus is identified and a 00 silk suture is placed at the superior and inferior border of the pylorus. With the cutting cautery current at 15 V the muscle tissue of the pyloric sphincter is divided and pyloromyotomy is performed; or alternatively, a Heineke-Mikulicz pyloroplasty is performed. The pyloromyotomy or pyloroplasty may be covered with a piece of omentum or previously mobilized falciform ligament and secured in place with previously placed 00 silk sutures.

The incisura is identified at the lesser curvature of the stomach and the right gastric artery is divided above the incisura. Multiple fires of green 4.5 mm linear stapler loads aiming towards the angle of His are used to create a gastric conduit approximately 4 cm in width. In cases where the tumor extends into the stomach, care must be taken to ensure an adequate distal margin. A second staple line can be fired parallel to the first to supply the pathologist with specimen to determine the distal margin status on frozen section examination. The conduit can be completely formed in the abdomen and transferred to the chest with traction sutures, or alternatively partially formed in the abdomen with completion of the tubularization in the chest after formation of the anastomosis. Using 000 silk sutures, the omental pedicle that is to be transferred into the chest is tacked to the staple line on the proximal stomach to facilitate transposition of the gastric conduit and omentum to the chest. A feeding jejunostomy catheter is placed 30 cm from the ligament of Treitz in Witzeled fashion. Finally, the abdomen is closed.