As the surgeon approaches the upper extent of the wound, he or she must avoid dividing the cervical cutaneous nerve, which lies in the superficial investing fascia (Figure 3). The sternocleidomastoid muscle is then retracted laterally and its fascial attachments along the anterior border are divided. The omohyoid muscle crosses the lower portion of the incision and is divided between clamps (Figure 4). Hemostasis is obtained by a 00 ligature. The inferior end of the omohyoid muscle is retracted posteriorly, while the superior end is retracted medially (Figure 5). As the middle cervical fascia investing the omohyoid and strap muscles is divided in the upper portion of the wound, the superior thyroid artery is exposed, divided between clamps, and ligated (Figures 4 and 5). The cervical visceral fascia containing the thyroid gland, trachea, and esophagus is entered medial to the carotid sheath. The posterior surfaces of the pharynx and esophagus are exposed by blunt dissection. The diverticulum is then usually easy to recognize unless inflammation is present, causes adhesions to the surrounding structures (Figures 6 and 7). If difficulty is encountered in outlining the diverticulum, the anesthesiologist can pass a rubber or plastic catheter down into it. Air is injected into this catheter to distend the diverticulum. The lower end of the diverticulum is freed from its surrounding structures by blunt and sharp dissection, its neck is identified, and its origin from the esophagus located (Figures 6, 7, and 8). Special attention is given to the removal of all connective tissue surrounding the diverticulum at its origin. This area must be cleaned until there remains only the mucosal herniation through the defect in the muscular wall between the inferior constrictors of the pharynx and the cricopharyngeal muscle below. Care must be taken not to divide the two recurrent laryngeal nerves, which may lie on either side of the neck of the diverticulum or in the tracheoesophageal groove, more anteriorly (Figure 8). Two stay sutures then are placed at the superior and inferior sides of the neck of the diverticulum (Figure 9). These are tied, and straight hemostats are applied to the ends of the sutures for retraction and orientation. The diverticulum is opened at this level (Figure 10), care being taken not to leave any excess mucosa and, on the other hand, not to remove too much mucosa to prevent narrowing of the esophageal lumen. At this time the anesthesiologist passes a nasogastric tube through the esophagus into the stomach. It can be seen within the esophagus as the diverticulum is divided (Figure 10). A two-layer closure of the diverticulum is begun. The first row of interrupted 0000 suture is placed longitudinally to invert the mucosa with the knot tied on the inside of the esophagus, gentle traction being used on the diverticulum to enhance the exposure. The diverticulum gradually is excised as the closure progresses (Figure 11). Then a second row of horizontal sutures closes the muscular defect between the inferior constrictors of the pharynx and the cricopharyngeal muscle below. These muscles are brought together by interrupted 0000 sutures. An alternative method is to divide the diverticulum with a linear stapler.