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HOW WE DO IT
When performing RE, we typically employ the 4-arm technique for both chest and abdominal
[36]
procedures . In the chest procedure, the ports are usually positioned on the anterolateral side due to its
reduced postoperative pain and advantageous access to the posterior mediastinum. Additionally, the vertical
placement of ports proves highly beneficial during esophagectomy, as it facilitates coverage of a vast area
extending from the neck to the diaphragm. This configuration proves especially helpful when conducting
extensive dissection in RE [Figure 3].

Based on previously mentioned studies and findings from our institute’s experience, we adhere to specific
principles when conducting LN dissection along RLN [Table 3]. We prefer employing the semi-
skeletonization method and performing a half-circumference dissection, particularly in left-sided
dissections. This involves keeping the RLN partially attached to the mediastinal structure rather than
completely detaching it. Typically, the dissection direction starts laterally and proceeds medially. While
energy devices can be utilized, we maintain a distance of five millimeters or more from the RLN to mitigate
thermal damage. In intrathoracic LN dissection along RLN, we consistently check the upper border of the
dissection to ensure proximity to the inferior thyroid artery.

When performing right recurrent laryngeal LN dissection, the initial step involves using robotic scissors to
open the mediastinal pleura. Afterward, identification of the vagus nerve (VN) ensues. The subsequent task
is to locate the right RLN, typically positioned just below the subclavian artery. This is generally more
straightforward than on the left side. LNs around the right RLN, designated as 106recR, become visible, and
the separation of vascular and nerve branches along the RLN commences. Progressing upward, the inferior
thyroidal artery is visualized, setting the upper boundary for nerve dissection. In this area, approximately
half of the lymphatic tissue comprises cervical paraesophageal LNs, while the other half constitutes
mediastinal intrathoracic LNs. Following the separation from the RLN, attached tissues are removed,
completing the right-side recurrent laryngeal LN dissection. During dissection of 106recR, the posterolateral
side is typically located superficial, sufficing dissection for the RLN LN. Deep dissection around the nerve is
generally unnecessary, and postoperative nerve palsy after right-side dissection is infrequent. This illustrates
the outcome after the complete dissection of the RLN, displaying the esophagus, trachea, and RLN
[Figure 4A].

Left-side dissection poses more challenges compared to the right side due to the greater length of the nerve,
necessitating a more radical approach. During left-side dissection, we typically prefer using a cold cut.
When utilizing an energy device, we ensure a considerable distance from the nerve to prevent thermal
damage.

We prefer to access the left RLN space anterior to the esophagus, between the trachea and esophagus.
Dissect the tissues to expose the aorta at the base. During this process, retract and rotate the trachea using
the #4 robot arm and use bipolar forceps to grasp the trachea. Intubation with a single-lumen endotracheal
tube with a blocker is essential for handling the trachea and for dissection along the left RLN.

After separating the esophagus and trachea, continue dissection downward until the left main bronchus is
visible. Ensure that the tissue between the esophagus and left RLN remains intact for easier subsequent
dissection. We aim to locate the left RLN near the left main bronchus bifurcation, as variations in the left
RLN are minimal in this area based on our experience. Occasionally, multiple nerves may be present;
typically, the middle nerve is the left RLN. To confirm, track the nerve caudally to identify the recurrent site,
which runs deep to the operative field. Then, continue tissue dissection cranially along the left RLN.