The easiest place to start the myotomy is on the distal esophagus 1-1.5 cm above GEJ. Grasp the 2 sides of the muscularis, folding the muscle into the jaws of the graspers. By streching the muscles to sides, the plane maybe clear. The LigaSure is then used to cut the outer layers of the esophageal wall muscles down to the submucosa. The submucosa will often appear bulging after the first application of LigaSure if the graspers were placed properly. The LigaSure's jaw can then be used to insinuate into the plane between submucosa and muscle and continue the myotomy upwards.