The region of the esophagus and fund us is next exposed and mobilized medially. The avascular suspensory ligament supporting the left lobe of the liver is first divided. The surgeon grasps the left lobe with the right hand and defines the limits of the avascular suspensory ligament from underneath by upward pressure with the index finger (Figure 9). This procedure is facilitated if the ligament is divided with long curved scissors held in the left hand. Occasionally, a suture will be required to control oozing from the very tip of the mobilized left lobe of the liver. The left lobe should be carefully palpated for evidence of metastatic nodules deep within the substance of the liver. The mobilized left lobe of the liver is folded upward and covered with a moist pack, over which a large S retractor is placed. At this time the need for upward extension of the incision, or removal of additional sternum, is considered. The uppermost portion of the gastrohepatic ligament, which includes a branch of the inferior phrenic vessel, is isolated by blunt dissection. Two right-angle clamps are applied to the thickened tissues as near the liver as possible. The tissues between the clamps are divided and the contents of the clamps ligated with transfixing sutures of 00 silk (Figure 10). The incision in the peritoneum over the esophagus and between the fundus of the stomach and base of the diaphragm is outlined in Figure 10.