The region of the esophagus is palpated. The peritoneum immediately over the esophagus is grasped with toothed forceps, and an incision is made in the peritoneum at right angles to the long axis of the esophagus (Figure 5). The incision may be extended laterally to ensure mobilization of the fundus of the stomach. Curved scissors are then directed gently upward to free the anterior surface of the esophagus from the surrounding tissue. This can be done by blunt dissection, using the index finger, which has been covered with a piece of gauze (Figure 6). Traction sutures of fine silk may be introduced into this peritoneal cuff to assist in visualizing the area. After 1 in. or more of the anterior wall of the esophagus has been freed from the surrounding structures, the index finger should be introduced beneath the esophagus from the left side. It is frequently necessary to loosen some adhesions in this area by sharp dissection. Usually, little difficulty is encountered in gently passing the index finger beneath the esophagus and its indwelling nasogastric tube and completely freeing it from the surrounding structures. Just to the right of the esophagus, the index finger will usually encounter resistance from the uppermost limit of the hepatogastric ligament (Figure 7). This portion of the structure should be divided, since its division affords more mobilization of the esophagus and tends to provide exposure of the posterior or right vagus nerve. The major portion of the hepatogastric ligament in this area is quite avascular and thin, so that it can be perforated easily with scissors or the index finger. A pair of right-angle clamps is then applied to the uppermost portion of the ligament, and the contents of these clamps divided with long, curved scissors (Figure 8). This exposes the region posterior to the esophagus and ensures adequate exposure of the hiatal region.