A blunt opening is made in the substernal cavity by spreading the scissors, while pulling the xiphoid ventrally with a sharp retractor.
After opening the substernal cavity, a substernal tunnel is constructed with an atraumatic clamp.
The sternum has to be pulled continuously, and the endothoracic membrane is to be separated from the sternum. A longitudinal incision along the anterior border of the left sternocleidomastoid muscle is made to expose the cervical esophagus. Blunt preparation with the hand through the substernal tunnel usually leads to rupture of the mediastinal pleura (A-1,A-2,A-3).
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